An NCAS good practice guide
1. Local performance procedures – the essentials
1.1 Maintaining patient safety and protecting the public
1.2 Writing policies and processes which are transparent and clear
1.3 Ensuring processes are fair
1.4 Guarding against discrimination and supporting equality and diversity
1.5 Supporting the practitioner and colleagues
1.6 Safeguarding confidentiality
1.7 Keeping procedures up to date
2. Identification of concerns
2.1 Acting promptly
2.2 Determining whether concerns relate to individuals or teams
2.3 Using teams to help individuals
2.4 Looking at early warning signs
2.5 Engaging with the practitioner
2.6 Understanding the influences on performance
2.7 Exploring any underlying health issues
3. Organisational structures
3.1 A decision-making process
3.2 Access to relevant expertise
4. Key processes
4.2 Performance assessment
4.3 Hearings and decision-making
5. Action planning and support
5.1 Protecting patient safety and service efficiency
5.2 Agreeing an action plan
5.3 Defining success criteria
5.4 Specifying the remediation mechanisms
5.5 Specifying support
5.6 Reviewing progress and sign-off
6.1 National Clinical Assessment Service
6.2 Education providers
6.3 ‘Next tier’ organisations
6.4 Professional regulators
6.5 Family Health Services Appeal Authority/NHS Tribunal
6.6 Local representative committees
6.7 Dental reference officers
6.8 NHS regulators
At a glance
No single model of local performance procedure is likely to suit all circumstances. Our aim has therefore been to identify the main elements to be considered in developing and operating effective local procedures for use in primary care organisations (PCOs). By ‘PCOs’ we mean the boards and trusts responsible for managing primary care locally across the UK.
Most PCOs already have performance systems in place so this document provides a framework for reviewing how they work. For people new to managing performance issues, it suggests how local processes can ensure that performance concerns are managed fairly and consistently. It also helps local managers think through how best to safeguard patient safety whilst preparing the ground for the practitioner to resume full unsupervised practice, where possible. It also gives advice to PCO managers on working with other agencies including the National Clinical Assessment Service (NCAS). Early local resolution of performance issues is the aim but, where concerns are more complex or serious, local managers may need to seek external help.
NCAS has published separate guidance on the conduct of local investigations so this publication deals with events before and after an investigation – identifying concerns and then taking action.
We have built on guidance set out in a 2006 NCAS publication, Local GP Performance Procedures (now withdrawn) and also on a joint Department of Health and NCAS publication Handling concerns about the performance of healthcare professionals (NCAS and Department of Health, 2006) (pdf 570KB).
Further NCAS guidance can be downloaded from our Toolkit.
refers to dentists, doctors and pharmacists; the groups within NCAS’ current remit, although organisations may find the guidance useful in other contexts as well.
‘Performance concerns’ include any aspects of a practitioner’s performance or conduct which:
pose a threat or potential threat to patient safety;
expose services to financial or other substantial risk;
undermine the reputation or efficiency of services in some significant way;
are outside acceptable practice guidelines and standards.
'Primary care organisation’ (PCO is used to describe the boards and trusts responsible for managing primary care across the UK.
Statutory Instruments (‘regulations’) and frameworks differ from country to country and across the professions, so it is important to access the relevant legislation and guidance. The ‘Must knows’ sections on the NCAS website provide quick links to key NHS legislation in each country and for each practitioner group.
For medical practitioners the introduction of responsible officers and the implications of re-validation will need to be taken into account in designing and operating local procedures. NCAS will update this guidance on its website as necessary.
In addition to the tools and processes described here, some performance issues may be addressed through NHS contract regulations governing the provision of dental, medical and pharmacy services. Contract provisions are not discussed because PCOs already have access to specialist contract management and human resource management advice.
Managing performance concerns can be complex. Performance problems may occur in isolation or in combination and their presentation may be subtle or disguised. The actions which a PCO may need to take can be strongly contested and livelihoods may be at stake. If actions and decisions are not to be challenged, any set of local performance mechanisms must have regard to these key issues:
maintain patient safety and protecting the public
writing policies and processes which are transparent and clear
ensuring processes are fair
guarding against discrimination and supporting equality and diversity
supporting the practitioner and colleagues
keeping procedures up to date.
risks associated with each case must be systematically evaluated. Performance concerns may relate to a single area of concern or be multi-factorial. Areas of concern include clinical errors, knowledge or skill deficits, outdated forms of practice, inappropriate attitudes, behaviour or conduct, dishonesty and other unlawful activity, poor interpersonal communication, as well as health and addiction problems.
The priority in local performance procedures is to assure and maintain patient safety and public protection. The question “Do we need to do anything immediately to protect patients?” needs to be considered throughout the process and particularly when significant new information comes to light. Other issues which might relate to the wider public interest (such as alleged serious fraud) need to be kept under consideration similarly.
The PCO can use its local knowledge of the practitioner’s work situation to decide whether restrictions on the practitioner’s work could be appropriate whilst further investigations or other actions are pursued. The level of insight shown by the practitioner into the situation that has arisen may also be pertinent, as will any action taken by another agency investigating the concern (such as the police or a regulator).
Local performance management policies and procedures need to be written and publicised in ways that ensure understanding. Up-to-date policies can be presented in searchable format on the PCO website with paper copies made available through local professional committees.
Examples of information that PCOs might publish to facilitate operation of local performance procedures include:
details of supporting structures, identifying which officers of the PCO and lay members of the Board are normally and formally involved in operating the procedures
what is meant by ‘local investigation of concerns’
how whistle blowers are protected;
where to find support for practitioners whose performance is causing concern
criteria and options for onward referral
the role of NCAS, and how to contact and work with NCAS advisers
the professional duty of individual practitioners and local practitioner bodies to raise concerns about performance, using local procedures and/or the professional regulatory bodies, as appropriate
funding arrangements for remediation and retraining including practitioner contributions
arrangements and timetable for reviewing local procedures, explaining how suggestions can be put forward for discussion
the PCO’s policy on recording, retaining and sharing of records.
In most cases (unless an external agency, such as the police, has requested that the practitioner is not informed of the concerns raised) it is good practice for a senior manager of the PCO (usually the medical director or equivalent) to speak with the practitioner and explain the concerns raised and the action being taken by the PCO. This provides the practitioner with an opportunity to make an initial response to the concerns raised, which could help the PCO to decide what if any further action needs to be taken.
Having started this dialogue, the manager should then maintain regular contact with the practitioner, reporting relevant case developments and being available to answer questions.
Fairness also requires that people who make decisions about concerns should not be involved in their investigation. If the case manager role is performed by a professional adviser to the PCO board (for example, a medical director or consultant in dental public health) the professional adviser should not act in a decision-making capacity later in the case.
All those involved need to be familiar with their responsibilities to avoid discriminatory action and to apply the health service’s commitment to equality and the positive recognition of diversity.
A PCO could monitor whether concerns about practitioner performance are being identified across the whole of the local practitioner workforce or whether there is disproportionate impact of some sort.
The investigation of performance concerns can have a significant impact on the individual practitioner, their practice, their colleagues and those raising the concern. The impact may be particularly marked when a practitioner is suspended from duties.
The PCO should consider what support could be offered and made available to them. For example the practitioner and, if appropriate, others could be reminded about access to the PCO’s occupational health service and counselling services, where provided, and also those services which are provided by their own employers, where applicable applicable. Further information on organisations that might help is available on the NCAS website.
Practitioners under investigation or the subject of a performance assessment can still be offered PCO help to identify someone to provide support through the process. This might be a personal friend or work colleague, or a nominee from the relevant local representative committee (LRC) , provided that they are not involved in local performance procedures in some other capacity. At any stage, the practitioner may also consult a defence organisation or professional association. In meetings with the PCO, the practitioner should normally be permitted to be accompanied by a friend and/or representative and be given reasonable time to consult with them prior to any meeting.
The PCO should take appropriate steps to ensure that, where necessary, confidentiality is safeguarded.
It would be unusual for a PCO to release detailed information about an ongoing performance investigation in respect of a specific practitioner, although in certain circumstances the PCO may wish to confirm that an investigation is underway. This could be necessary if press enquiries are being made about what action a PCO is taking in respect of a specific incident, for example.
Good local governance requires that the PCO’s local performance policies and procedures are reviewed regularly to ensure they remain up to date and in line with national policies and guidance. The dates or frequencies for the review of procedures should be included in the procedure document to ensure that practitioners and their representatives are clear about update intervals as a matter of course.
NCAS advisers can help with local policy reviews. NCAS also has an educational programme of workshops to help managers developing and operating local procedures, see NCAS Events for further details.
Box 1 summarises how to ensure that processes are fair (see below).
Box 1 – Ensuring that processes are fair
Ensure that any process is fair and reasonable and complies with relevant regulatory and/or statutory provisions. For example:
- any decision-making panel or committee of the PCO must have formally - delegated authority to carry out its functions;
- panel members should ensure that no conflicts of interest prevent them from sitting on the panel;
- no-one appointed to undertake an investigation should take, or be involved in taking, any subsequent decision about formal action against the practitioner, such as suspension, removal or contingent removal from a practitioner list;
- the PCO may need to consider whether it would be appropriate to allow legal representation if a case for removal or contingent removal is complex or where allegations against the practitioner are extremely serious or of a quasi criminal nature;
- any formal decision should be in writing and be clear and rational.
A panel’s decision could be said to be unfair or unlawful if:
- there is not clear separation of members involved in investigation and decision making;
- the PCO has not permitted legal representation and cross examination of witnesses (even if these are not required in local procedures);
- the procedure set out in the legal framework has not been complied with;
- the decision can be shown to be irrational.
Identifying that there is a concern and discovering its nature can be difficult. Low level concerns in isolation may seem insignificant but, taken together, can indicate a problem requiring action. Drawing a line between inaction and action needs skill and experience. Local managers should have processes and policies which show that in responding to concerns they are:
determining whether concerns relate to individuals or teams;
using teams to help individuals;
looking at early warning signs;
engaging with the practitioner;
understanding the influences on performance;
exploring any underlying health issues.
Concerns can be reported in a range of ways and there is no simple set of indicators to define ‘poor’ performance. A PCO might start to become concerned about a practitioner’s performance through review of information already collected and analysed for operational purposes. This could include prescribing data, data on referral rates, and findings from practice and pharmacy inspections. In using such data, keep in mind that satisfactory team performance indicators may mask concerns about individuals and this may need to be addressed through further specific inquiry or investigation.
Other sources will probably relate to more isolated events – concerns raised by colleagues, or from patient complaints, for example. The list of potential information sources is long and includes:
partners and colleagues of the practitioner, local professional groups, out-of-hours service providers, community or practice nurses, pharmacists, secondary care clinicians
appraisal processes, if a serious concern arose during an appraisal interview
individual patients and organisations working with patients
the professional regulatory body
the clinical governance system
incident-reporting systems and certain unexpected incident procedures
local professional committees and groups
the Dental Reference Service
people or organisations outside the health service such as police, coroners, local press or the courts.
Some concerns will seem to call for more urgent responses than others. Patterns of poor performance may tell the PCO more than isolated incidents but there is no simple definition of a ‘pattern’ either. The important need is to have a way of pulling together all local intelligence and seeing where links could add up to a significant concern needing attention. Anonymous reports may be difficult to verify but should not be dismissed. On their own they may not support formal action, but they can lend support to other evidence.
Most guidance and research on performance difficulties centres on the individual clinician. The possibility that an individual’s under-performance is linked to wider team dysfunction also needs to be considered. NCAS itself will not undertake team reviews but advisers can help PCOs identify ways of investigating team dysfunction, including commissioning work from occupational psychologists.
NCAS has developed a specification for a team review process through consultation with experts in the field and has identified providers able to meet the specification. Access to the NCAS-specified team review process is through the NCAS Adviser.
The purpose of a team review is to:
provide an independent view on team inputs and process, within the wider context of the organisation
identify satisfactory areas of functioning and areas of concern
identify factors that may be contributing to these concerns
make recommendations for addressing any difficulties identified.
The review has been designed to be developmental – that is, it aims to bring about improvement in the team as a whole and help team members work better together through improved understanding of each others’ values, skills and working methods.
A team review will not assess the quality of care provided by the team because it may not be carried out by clinicians. If a PCO has concerns about the quality of care being offered by a group of practitioners, it should seek assistance from NCAS to help it decide if individual assessments, a team review or assessment is appropriate.
Sometimes concerns may be raised about a practitioner who is working in a practice which is known to include experienced and supportive colleagues who may be able to help without need for more formal measures. The practitioner may be new to the area and working with unfamiliar systems which have led to some errors, for example. If a potential problem is identified outside the practice, then a first step for the PCO might be to discuss it with the practitioner and, if appropriate, ask whether the practitioner would be willing to discuss it with a trusted practice colleague. This will need sensitive handling but may be a good way of getting remedial support in place quickly.
PCOs can also encourage teams to raise any concerns about the performance of a colleague as early as possible by providing a named person to contact in the PCO. Teams may want to talk through a concern with the PCO and, again, the PCO may be able to help a team use informal learning opportunities to prevent minor concerns becoming more serious.
Early warning signs can take a range of forms but routinely-collected management statistics are likely to feature on any PCO’s list. Common sense says that statistics collected for one purpose may be useful for another and possibilities should be explored. But the PCO must also recognise that working differently may not be wrong and a practitioner who is a ‘statistical outlier’ may not be a poor performer.
Alerting systems need to be transparent and credible. It will not normally be appropriate to base decisions on a single indicator.
The various strands of intelligence then need to be brought together into an integrated information system which allows practitioner performance to be compared with local norms and, where practicable, with relevant and accepted national standards. Regular review of early warning signs should be built into local clinical governance processes. They may be less sensitive than more immediate day-to-day observation by colleagues, but they can be a good starting point.
As a general principle, NCAS encourages employers and contracting bodies to be transparent and to communicate and engage early with the practitioner whose performance is causing concern. NCAS suggests that wherever possible, an appropriate senior officer of the PCO (usually the medical director or equivalent) has an early meeting with the practitioner to explain the nature of the concerns raised and the action the PCO is considering. This will help the PCO make a preliminary evaluation of the situation and determine further action, if any.
Exceptionally, contact with the practitioner may have to be deferred if a counter fraud agency or the police advise that early meetings or early disclosure could compromise subsequent investigations.
A clinician’s performance may reflect a number of factors including clinical skills, education, physical and psychological health, personality and attitudes as well as the working environment, the immediate team and workload. When investigating concerns managers should look systematically at how each factor might be contributing to the concerns.
An NCAS report, Understanding performance difficulties in doctors (2004) (pdf 193kb) discusses these factors and is relevant to the work of dentists and pharmacists as well as doctors (see Publications). The report points to the following questions:
is there a difficulty with clinical knowledge and skills?
is there a deficiency in education and continuing professional development (CPD)?
is there a physical illness?
is the practitioner depressed or suffering from mental illness?
is he/she subject to additional pressures – at work or at home?
might alcohol or substance abuse be involved?
could there be cognitive problems?
have there been changes in the working environment?
are there team difficulties?
have there been major organisational changes?
are there wider organisational difficulties/systems failures that maybe contributing to the concerns?
Practitioners, like everyone, may have health concerns from time to time. About a fifth of NCAS cases include a concern about health. The PCO should be alert to hidden messages in contacts from colleagues, family and friends who may know that there is a problem but are worried about damaging the practitioner’s career.
Practitioners should know and believe that they can access professional and confidential care, quickly and effectively. The PCO should consider how practitioners can be reassured that if they refer themselves or colleague with potential health concerns, the PCO has mechanisms in place to deal with the matter sensitively and so far as possible confidentially. The PCO might identify a named person as a point of contact for raising health-related related concerns, for example. The PCO should also be open about its willingness to help practitioners access support and treatment, using either an occupational health referral or the practitioner’s own GP.
Where a practitioner has health problems which may have an adverse impact on their performance (for example alcohol or substance abuse, serious physical or mental illness) action will be required to safeguard patients. The PCO should normally discuss the problem directly with the practitioner. It may be appropriate to advise a period of sick leave while an occupational health assessment is arranged. In some situations it may be necessary to consider whether suspension from the performers list would be appropriate. Referral to the regulatory body may also be necessary if the practitioner is not cooperating with local processes or the PCO does not have any regulatory controls available to it in relation to the individual practitioner.
The prototype Practitioner Health Programme (PHP) in London provides a service to dentists and doctors living or working in London and with physical or mental health concerns or addictions.
The relevant LRC may also be able to help the individual to access appropriate personal support and the NCAS website includes a list of voluntary support networks.
In setting up local performance management systems, PCOs should observe and use rules and mechanisms laid down for them by their national health departments. For example, Scotland's health boards can access the support of the Central Discipline Unit when required. Although this means that there cannot be a standard UK-wide structure, there should certainly be common elements.
NCAS also recognises that a range of local arrangements have been developed within each country and many are working well. The models described here are not intended to undermine good local systems. They are, however, based on systems which NCAS has observed working well for dental and medical practitioners, and which have the potential to be extended to pharmacists and other health professionals.
A diagram on the inside back cover of this guide summarises the performance management process and emphasises the distinction between fact finding and decision-making. The key building blocks for effective local performance governance are:
Good local governance requires clear procedures for making decisions about concerns relating to practitioner performance. NCAS suggests establishment of a decision-making group (DMG) with a remit to ensure that the facts are ascertained, appropriate decisions are made and, where necessary, appropriate action is taken. Action should be in accordance with the relevant regulations and should include, if appropriate, onward referral to another agency such as the police or a counter-fraud agency or professional regulator.
Membership and size is for local decision, although a DMG should normally be kept small to reduce the risk of inappropriate disclosure of sensitive information and make it easier to arrange meetings at short notice. There should be at least one lay member. Where PCOs have chosen to work together on operational issues and the group has formally delegated powers from more than one PCO, the group may need to be larger. Lay membership is needed for performance systems to have public confidence.
DMGs usually have three or four members including a chairperson and a lay member. Membership might include:
the PCO chief executive;
one or more other senior PCO officers, e.g. medical director, consultant in dental public health, senior pharmaceutical adviser, Professional Executive Committee (PEC) chair, senior human resources manager; the PCO chair, or other non-executive board members;
a member from an LRC.
The DMG's interface with the responsible officers for medical practitioners (once appointed) will need to be considered.
To ensure fairness, people who make decisions about concerns should not be involved in their investigation. If the case manager role is performed by a professional adviser to the PCO board (for example, a medical director or consultant in dental public health), the professional adviser should not be appointed to the DMG or be part of any subsequent panel hearings. It may be necessary to appoint a professional adviser from another PCO to deputise at decision-making meetings. Alternatively, a DMG might take independent expert advice, calling the adviser as a witness and allowing cross-examination, where necessary.
Note that the LRC member could have full membership or observer status only. As an observer, the representative’s remit would be to check that local procedures are being applied fairly and provide expert help on contractual issues and professional standards. This function is quite separate from the LRC’s pastoral role in support of practitioners in difficulty, which should be filled by a different member of the relevant LRC. In Scotland area professional committees are configured differently, being part of professional associations rather than part of the NHS.
The DMG will need to be supported by someone whose job description includes managerial responsibility for the group’s procedural and administrative tasks and for accurately documenting all decisions. The group must be properly constituted under its standing orders and/or standing financial instructions, and Board minutes will need to reflect this. The DMG should have a written constitution providing for properly-delegated powers to act as a sub-committee of the PCO in exercising powers under the Regulations.
It would be good practice for the DMG to give the PCO board regular anonymised reports of numbers and types of cases dealt with.
After identifying a problem but before reporting it to decision-makers for action, a concern should be considered by an appropriate expert group – a Performance Advisory Group (PAG). Depending on local arrangements, such a group might:
undertake detailed investigations
help the DMG draw up development and training plans for individual practitioners
liaise with the deanery or other professional training organisations
identify, train and support a pool of clinical supervisors and mentors available to work with practitioners in difficulty
report locally on trends in performance concerns, and share experience with similar groups to improve understanding
advise at DMG meetings, via the attendance of one of the PAG’s members, but without the member being expected to participate in decision-making
advise PCOs about further action and monitoring of performance management.
PAG members should have in-depth knowledge of performance procedures and of the ethical and legal issues involved in the investigation and management of performance concerns. They should not make decisions relating to possible performers list action or referral to other bodies because that must remain the function of the DMG. The PCO will need to determine the mechanisms by which the PAG receives and actions referrals made to it and the governance links to the DMG and the board.
A multi-disciplinary membership will be desirable. For example, members might include a PCO clinical governance lead, a PCO manager with primary care experience, an educator, a practice manager, a practice nurse, a member from each of the LRCs, a PCO board member, a member nominated by the deanery, as well as other sources of specialist advice as necessary – a prescribing adviser, for example. As for the DMG it will be important to have lay involvement.
While a PAG might cover more than one PCO, this does not stop a panel being convened to advise only one of them. Whatever the model, roles and responsibilities, ways of working need to be established between the PAG and PCOs at the outset. These will cover, for example, training for members, record keeping, systems for handling
The PAG’s terms of reference and accountability systems should be formally agreed by the parent PCOs, using a service agreement. Contracts between PAGs and constituent PCOs will need to be reviewed as local procedures evolve. Where a PAG undertakes an investigation on behalf of a PCO, the terms of reference should be clearly stated, and the report provided by the PAG should distinguish clearly between findings and conclusions.
While the PAG model for handling individual cases of concern has a number of benefits, it is not the only model possible. Another option, which could run alongside or as an alternative is a Performance Support Unit (PSU). This would provide for a small, dedicated team at the level above the individual PCO, jointly funded to receive referrals from constituent PCOs and plan and support educational programmes for practitioners who have been assessed by NCAS or their regulatory bodies. Whatever the precise model adopted, PCOs should look for mechanisms which can be adapted to work with professions beyond dentistry, medicine and pharmacy, which give value for money and which support, for example:
sharing of case management experience and expertise with stronger working relationships between PCOs and deaneries;
consistency of approach between PCOs and professions;
ongoing reflection and learning about performance management of practitioners.
NCAS advisers will not act as PAG members but they could be invited to provide advice on the handling of a specific case. It will be important for the meeting agenda to be agreed in advance so NCAS staff attend only for those cases where NCAS has a role. It would not be appropriate for an adviser to provide advice on a specific case where contact had not previously been made with NCAS (i.e. where there was no case number or open case file).
Following the meeting, the NCAS adviser would normally write to the chair of the PAG summarising the points made by the adviser in the course of the meeting, for attachment to the minutes. Training, appropriate to the nature of the role to be performed, is important for all those involved in applying local procedures, including members of DMGs and PAGs, and especially for those people responsible for undertaking investigations and those who are responsible for supporting practitioners in difficulty. Training needs will depend on the relevant level of experience of those involved but all should receive induction training and equality and diversity training to ensure that the procedures are applied fairly and consistently summarises the roles of supporting organizations (see below).
Box 2 – Performance procedures - who does what
The PCO, via its DMG:
has overall responsibility for the management of practitioner performance as part of clinical governance;
decides on the actions required on individual performance cases;
makes referrals to other bodies including NCAS, regulators or police.
is an expert resource for PCOs;
carries out further investigation of cases or provides the PCO with advice on how to conduct an investigation itself;
shares lessons and trends with partner organisations involved in performance management of practitioners.
The deanery or education provider:
advises on planning and provision of training programmes following local performance procedures or NCAS assessment;
advises on recruitment, training and provision of staff to supervise educational and other developmental programmes;
collaborates with other deaneries and educational systems on common standards for competencies, trainer training and quality assurance.
provides advice and training on PCO performance structures and policies;
advises and helps at all stages of management of referred concerns;
carries out performance assessments of individual practitioners;
liaises with other bodies such as NHS and professional regulators to develop thinking on all aspects of practitioner performance management.
There are three key processes which a PCO’s performance management procedures should cover:
An investigation into the performance of an employee or contractor may be necessary for a number of reasons including, for example:
concerns expressed by other health professionals, staff or students
complaints about care made by patients, relatives or carers
concerns arising from clinical audit and other clinical governance activities
issues arising from an appraisal
an investigation into a serious untoward incident
information from the relevant healthcare regulator
information from the police
information from the coroner or procurator fiscal
anonymous complaints and allegations
other ‘soft’ information.
There should be a careful preliminary evaluation of the information to decide whether further exploration is required or whether there are sufficient grounds to justify a formal investigation. Once the decision to undertake a formal investigation is made, the PCO should:
define clearly the nature, purpose and scope of the investigation;
appoint a case manager to oversee the investigation process;
where appropriate, appoint an experienced person as case investigator;
inform the practitioner about the investigation and, where appropriate, give access to appropriate support.
The investigation should then proceed, the case manager ensuring that it is completed in a timely manner and that it is comprehensive, documented and makes clear the evidence that has been obtained and on which the conclusions rely.
More comprehensive NCAS guidance on How to Conduct a Local Investigation can be found in our Publications section.
A performance assessment should be carried out by trained assessors, looking at a practitioner’s practice using a systematic and standard approach to form a more detailed view about performance and identify factors that may have led to a performance difficulty. This may be particularly relevant where a local investigation has not produced sufficient information to enable a clear way forward to be identified.
Assessments are undertaken by different bodies for different purposes. Some, including NCAS assessments, seek to identify factors that may have led to the performance difficulty in order to define a developmental programme. By contrast, assessments by the professional regulators determine fitness to practise and have a summative purpose.
Some deaneries carry out educational assessments which can be commissioned by the PCO to guide remediation in focused areas of practice, particularly where an investigation has identified a specific area of concern.
Another option for PCOs is to carry out a review or assessment of aspects of a practitioner’s performance as part of an investigation. A review of records or prescribing patterns could inform a local action plan, for example. Local assessments of this type, used as part of an investigation process, should not be confused with the fuller performance assessment undertaken by NCAS.
NCAS assessments aim to clarify concerns, to identify factors which may be contributing to the concerns and to make recommendations as to how the difficulties may be addressed. Assessment methods and instruments are introduced in the NCAS Handbook, (see Publications) and explained in more detail at NCAS Assessment Services.
However the assessment or review is carried out, there is a possibility that it identifies serious concerns about the care provided by a practitioner to patients seen over the months prior to the investigation or assessment. In such cases it may be necessary to undertake a ‘duty of care’ review, looking at patient records or recalling patients for a consultation with another practitioner to determine whether they need additional investigation, referral or treatment. NCAS can advise on how this may be organised.
See Box 3 for a summary of how to decide whether NCAS assessment would be appropriate.
Box 3 – NCAS assessments
An NCAS assessment is likely to be appropriate where:
concern(s) are documented and the PCO is confident that the expressed concerns are accurate statements;
concern(s) are significant – the actions about which concerns are expressed do not meet what a practitioner would be reasonably expected to do in similar circumstances;
concern(s) are repetitious – ongoing problems, and/or problems on at least two separate occasions;
concern(s) do not appear to be sufficiently serious to warrant an immediate referral to the individual’s professional regulator;
the PCO has taken steps to manage the case but has not been successful in clarifying the concerns and/or bringing the case to a resolution; and/or
an NCAS performance assessment appears to offer a likely way forward in enabling the PCO and practitioner to bring the case to a resolution.
Decisions affecting the formal status of a practitioner on a performers list must be reached in accordance with the procedures set out in the relevant regulations and statutory provisions. Legislation differs across the four countries of the UK and different organisational models are set out in the associated guidance. See Box 4 for an outline of how a panel hearing might be conducted.
In broad terms, in relation to performance matters in England, the Performers List Regulations 2004 give primary care trusts (PCTs) the power to suspend, remove or contingently remove dental or medical practitioners from their performers list. Similar powers are available to local health boards in Wales. There is no requirement in England and Wales for there to be an oral hearing but the practitioner must be offered the opportunity to put his case. The running of the hearing on the day is at the discretion of the panel chair. In England and Wales, PCOs are advised to seek NCAS advice before suspending or excluding a dental or medical practitioner or a pharmaceutical contractor. All suspensions and exclusions must be reported to NCAS once they have been made.
For some dental or medical practitioners directly employed by English PCTs to provide primary care services, provisions of the framework document Maintaining High Professional Standards (MHPS) may also be relevant, even though the practitioners will be on a performers list if they want to provide primary care services.
The relationship between Performers List Regulations and MHPS is not necessarily straightforward in these circumstances, but PCTs would normally find it simpler to take action under Performers List Regulations even though there have been situations where a PCT has also used MHPS. The introduction and explanatory note to MHPS ‘excludes those who perform PCT Medical Services for the exercise of those functions’, as far as they were covered by the Primary Care List System. It could therefore be construed that practitioners in non-medical professions might be dealt with under either, or potentially both, procedures although NCAS advice would normally be to use performers’ list powers.
In Scotland, health boards may refer cases involving family health services (FHS) practitioners to the NHS Tribunal, possibly requesting the Tribunal to direct interim suspension before a substantive hearing is held. The sanctions available to the Tribunal are national conditional or national unconditional disqualification. Health boards have sanction powers (withholding from remuneration warning or for dentists, prior approval) under the NHS (Discipline Committees) (Scotland) Regulations 2006.
In Northern Ireland, discretionary removal of a medical practitioner would need to be actioned through application to the NHS Tribunal (Northern Ireland). Boards now have the power to impose suspensions of medical practitioners only. Any discretionary disciplinary action against a dentist or pharmacy contractor would need to be progressed through the Tribunal route.
Dental performers lists are only used in England and Wales. Legislation governing dentists in Northern Ireland and Scotland can be found on the NCAS website in the ‘Must know’ sections, alongside key medical and pharmaceutical legislation. Go to Must knows.
The principal means by which the profession of pharmacy is regulated within the NHS in England is through the Pharmaceutical 2005 Regulations. These provide for a Pharmaceutical List to be maintained and set out the circumstances under which the NHS must or may include a ‘chemist’ (as defined in the regulations), the sanctions available and an appeals process. Those included on the Pharmaceutical Lists may include bodies corporate and partnerships as well as individual pharmacists.
The NHS is unable to take action under its contractual arrangements against any individual pharmacist who is not on a Pharmaceutical List. Although different Pharmaceutical Regulations apply in the four countries of the UK, they all presently have the same limitation of allowing action only against pharmacy contractors and not individual pharmacists (unless the individual is also a pharmacy contractor or on a Pharmacy List). It remains open to the PCO to refer individual pharmacists to the relevant regulator.
Box 4 - How a panel hearing might be conducted?
The case manager presents the case, calling any witnesses agreed by the panel chair. The panel asks questions of each witness in turn, at the end of which each witness is allowed to leave.
The chair invites the case manager to clarify any matters arising from the presentation of the case on which the panel requires further explanation.
The practitioner then responds, calling any witnesses agreed by the panel chair. The same procedure for dealing with witnesses is used and the witnesses are allowed to leave, in turn.
The chair then invites the practitioner to clarify any matters arising from the response on which the panel requires further explanation.
The chair invites the case manager to make a brief closing statement summarising the key points of their case.
The chair invites the practitioner to make a brief closing statement summarising the key points of their case. Where appropriate this statement may also introduce any grounds for mitigation.
The parties then leave and the panel considers its decision.
This outline is based on Maintaining High Professional Standards in the Modern NHS, Department of Health, England, 2005.
Once a performance concern has been identified and investigated, possibly through formal assessment, the PCO may decide that it is appropriate for the practitioner to stay in local practice, but with support and a remediation programme in place to attempt to resolve confirmed concerns. In most cases this should include a structured plan to return the practitioner to full unsupervised practice.
NCAS advisers can help draft or review such action plans, which may also be drawn up for practitioners returning to work after periods of prolonged absence. For contractors, the plan should normally be set out in a formal signed agreement between practitioner and PCO. For employees, a joint action plan agreement should also involve the employer. These are the main points to consider:
protecting patient safety and service efficiency
agreeing an action plan
defining success criteria
specifying the remediation mechanisms
specifying resources and support
reviewing progress and sign-off.
Patient safety must be the first priority throughout the process of handling concerns about performance and devising an action plan. The PCO will need to consider whether temporary restrictions might be needed on the scope of clinical work and examine available colleague support. A practitioner undergoing remediation training should have someone to turn to if difficulties are encountered. If support is not available then it may be necessary to arrange a training placement. The NCAS Back on Track Framework document discusses these issues in more detail.
Practice restrictions might include requirements not to treat particular categories of patient or only to use certain procedures in certain specified circumstances.
On completion of the action plan the practitioner ought to be able to assure the PCO that performance is no longer impaired and any restrictions can be lifted. If the practitioner cannot do this then further action will need to be considered.
In NCAS terms, an ‘action plan’ is a formal agreement between practitioner and contracting/employing body. It is a way of engaging the practitioner and gaining commitment to making specified performance improvements within a defined timescale. The plan will define roles and relationships during the remediation period
and specify how remediation process will be brought to a close. If agreement to an action plan cannot be reached then the PCO may have no alternative but to take formal action or refer the matter elsewhere. The practitioner needs to be made aware what will happen if the remediation process is successful and the consequences of an unsuccessful remediation process.
The Back on Track framework suggests a staged process to agreement, starting with an outline plan of objectives and mechanisms and agreement in principle. If there is no agreement at that point then working on a more detailed proposal will be a waste of time and some other route must be taken. But if the practitioner and other parties are in broad agreement after preliminary discussion then a detailed plan can be drawn up for discussion and formal agreement through signature.
Depending on its scope and content, an action plan may entail costs in several areas – ongoing practice costs and pay costs for the practitioner if work time is shifted into training, locum cover for training time, and placement/coaching or other educational costs. The PCO will have management costs in addition. Costing an action plan and agreeing with the practitioner how it will be paid for will be a key part of the planning process.
Some PCOs have been willing to fund or part-fund return to work programmes, possibly for a defined period followed by review. Any further funding can then be made dependent on demonstration of reasonable progress. If an action plan has been recommended following use of national or local performance procedures, the practitioner should normally make a reasonable contribution, using loans if necessary, which can be repaid when normal working resumes.
The plan should contain clear objectives and milestones with an agreed timetable for review. This gives the practitioner targets to work to. The plan should also define roles, so that the practitioner understands who will be reviewing and who will later be taking decisions based on review outcomes. The roles envisaged in the Back on Track framework are:
Examples of success criteria might include:
assessment of patients’ conditions will be logical, focused and accurate
appropriate and timely attention to patient feedback
active participation in audit cycles
completion of a reflective learning log of personal development.
The plan will need to state where and how the practitioner will work during the programme – whether within the practitioner’s own practice (internal) or in an established training practice elsewhere(external).
With internal training, clinical supervision is provided within the practitioner’s own practice for perhaps one day a week, depending on patient safety and identified learning needs (occasional supervision). The advantage for the supervisor is the opportunity this provides for observing and understanding the impact of working relationships, practice organisation and other factors which may impact on performance. There may be opportunities to provide help to improve practice work systems.
The advantage of external training is that a training practice team will have experience of, and structures in place for, supporting learning. The practitioner also has the opportunity to experience a well-organised practice and its systems,and to participate in a stimulating and motivating work environment. Such supervision is likely to be direct initially, becoming more distant as progress is made. Following an external placement a planned process will be needed to help the practitioner re-integrate into their own practice.
Whether internal or external training is used requires an experienced trainer who will have had additional training in helping with performance problems. The aim is to help the practitioner meet the educational objectives of the action plan. The supervisor needs to assess the practitioner’s progress against objectives and make periodic reports to the PCO on progress.
Some PCOs offer help with team development to improve practice systems and the use of other resources in the practice. Practice nurse networking and IT development for the team can be useful, for example. Possibilities such as these should be considered when deciding where remediation training should take place.
The plan should also specify the educational activities that the practitioner is expected to participate in. These might include:
video recording and reflective review of consultations
PCO-based learning initiatives – these may be multidisciplinary ‘protected time’ sessions
multi-practice audit cycles
small group work with peer support
collecting comparative practice information which enables practices to assess themselves in relation to peers
critical incident analysis.
If the plan sets out specific educational requirements, the PCO needs to ensure that the practitioner has ways to demonstrate that the requirements have been met and give the PCO the evidence on which to base a decision.
Key mechanisms for supporting the practitioner are coaching and mentoring, which will probably take place alongside more formal educational activity.
Mentoring takes place when an experienced, well-regarded and empathic colleague (the mentor) guides the practitioner in personal and professional development. Mentoring may be wide-ranging,covering clinical work, professional relationships and career plans. The PCO should ensure the mentor has received training and is acceptable to the practitioner. The mentor should listen and talk to the mentee in confidence and should not report these discussions back to the PCO. The practitioner might be asked to maintain a reflective learning log which would form the evidence base for meetings.
Coaching helps a practitioner address behavioural issues that might have been identified during assessment or investigation. The coach helps the practitioner reflect on their behaviour and develop more appropriate behaviour patterns.
Further resources for support and training may be available from:
deanery appointees or others, acting in an advisory capacity
advanced or developmental trainers
clinical specialists within the PCO (for example, advisers on prescribing, infection control, pharmaceutical and dental advisers, clinical governance leads)
PCO education leads
‘buddying’ schemes with other practices
practice-based commissioning consortia (except in Scotland).
The action plan defines the review process and gives the PCO a basis for deciding, based on evidence gathered, whether to sign off the programme and let the practitioner resume work within normal appraisal and support mechanisms, or whether to take a different course, including, possibly, list removal or referral to the professional regulator.
The same choice exists for the PCO at earlier review points. If the evidence shows that progress is not satisfactory, or if the practitioner does not cooperate, the remediation process can be ended before completion. It can also be extended if there is agreement between practitioner, manager and educational adviser(s) that a further period of remediation could be expected to bring benefits.
The PCO and the case manager – the person responsible for progressing the PCO’s handling of a performance concern – do not need to work in isolation. They can consult with NCAS and other partners at any stage to ensure that a performance concern is handled appropriately and effectively. This does not diminish the case manager’s responsibility to manage the case on be
The PCO’s partners include:
National Clinical Assessment Service
‘next tier’ organisations
Family Health Services Appeal Authority (FHSAA)/NHS Tribunal
local representative committees
dental reference officers
NCAS offers advice to PCOs via a network of trained advisers. Advice can be requested at any stage of managing a performance concern, though NCAS would prefer to be involved early. Asking for advice does not mean that the practitioner will have to undergo formal assessment – only about one referral in 17 takes this course. Nor is NCAS advice reserved for more 'serious' cases. NCAS will take calls about any concern, even if it is not yet clear whether the concern represents poor performance. Equally, NCAS will respond to requests for help with long-standing cases.
Contacting NCAS does not commit the PCO to making further use of NCAS services, but PCOs should be aware that they may be criticised (for example on appeal) if they decide not to follow NCAS advice and are unable to show good reason for such a decision. Contact with NCAS is usually made by the PCO’s medical.
NCAS provides a service to the whole of the UK and works with both NHS and independent sector providers of healthcare. More information about NCAS services can be found in the NCAS Handbook at NCAS Publications.
Training for doctors who have completed their pre-registration year is coordinated and delivered through local postgraduate deaneries. The deaneries also work with dentists. They aim to improve the quality of patient care by ensuring that dentists and doctors are well-educated, trained and motivated. There are separate arrangements for pharmacy training which may be provided by employers or other commercial training organisations.
The role of education providers in managing performance concerns varies between countries and regions. However, areas of work that they might be expected to be involved in include:
responding to local patterns of performance concerns by advising on relevant training courses and other educational opportunities
providing advice to PCOs on the education aspects of individual cases
advising a PCO on whether a programme of retraining is an appropriate response to a problem and, where such a programme goes ahead, providing regular progress reports to the PCO
- working with individual practitioners referred to them by the PCO or the professional regulatory body to advise on a tailored programme of support and training
providing training to PCO staff and practitioners involved in performance procedures on their roles and responsibilities (except in Scotland).
NCAS has agreed ‘memoranda of understanding’ with the Committee of General Practice Education Directors (COGPED), the Committee of Postgraduate Medical Deans (COPMED), and the Committee of Postgraduate Dental Deans and Directors (COPDEND). These agreements set out how NCAS and educational work can be co-ordinated. The agreements can be found at Our
Arrangements for overseeing PCOs differ across the UK. In England strategic health authorities (SHAs) performance manage PCOs, whereas in Scotland boards are directly accountable to the Scottish Government. The overseeing role may include:
ensuring that local systems for handling concerns about performance are operating well, by gathering information about the numbers of cases, their progress and outcomes, for example:
ensuring that there are arrangements in place for further training and support of practitioners about whom there is concern. This will include working with deaneries and bodies developing the workforce
helping PCOs handle occasional high profile cases, for example by giving advice on how to deal with media interest
scrutinising the use of suspension and exclusion from work.
NCAS will not normally have contact with the relevant next tier organisation when advising on cases. However, there may be instances where discussion with the next tier organisation could be appropriate, for example, regarding a PCO failure to follow up assessment recommendations. In such a case, NCAS would normally inform the PCO of its intentions first.
The bodies which regulate practitioners – the General Dental Council, General Medical Council and (from April 2010) the General Pharmaceutical Council – do so in accordance with UK legislation. Their key concern is that registrants continue to be fit to practise. The regulators do not expect to be involved with complaints of a minor nature or with performance problems which are being resolved locally and which do not raise questions about a practitioner’s entitlement to be registered.
Regulators can take action when:
a registrant has been convicted of a criminal offence
there is an allegation of serious professional misconduct
there is a serious deficiency in performance which is a risk to patients
there are health issues which, if the practitioner continues to see patients, might compromise patient safety.
The regulators for dentists, doctors and pharmacists can suspend a practitioner’s registration as an interim measure, pending the outcome of a full hearing, if there is evidence that patients may be at risk.
The FHSAA and the NHS Tribunal are independent bodies dealing with performers list disqualifications and appeals, the FHSAA working in England and Wales and the NHS Tribunal in Scotland.
Amongst other matters, the FHSAA considers:
appeals from dental and medical practitioners who have been refused inclusion on performers list or the local list of practitioners
appeals from dental and medical practitioners who have been removed or contingently removed from the performers list
applications from PCOs for national disqualification of practitioners from all PCO lists
cases relating to pharmacy contractors refused entry to pharmaceutical lists.
The NHS Tribunal hears applications from health boards in Scotland for unconditional and conditional disqualification. In Northern Ireland , the appeals are made to the Department of Health, Social Services and Public Safety.
In Scotland, the Scottish Government Health Directorate’s guidance and regulations govern procedures relating to NHS Discipline Committees and the NHS Tribunal. The central secretariat at NHS National Services Scotland (NHS NSS) provides support for the discipline committees and the clerk and deputy clerk (both legally qualified) support the Tribunal. The investigation may be carried out by the Practitioners Services Division (PSD) of NHS NSS, and the report made to the Health Board, with recommendations on further action to be taken, including referral to a NHS discipline committee or the NHS Tribunal
Local representative committees are elected bodies which represent the views of local dental, medical and pharmaceutical practitioners to PCOs, other health service bodies, and a range of other statutory and voluntary organisations. They should, and in many cases in England, Northern Ireland and Wales must, be consulted by PCOs on issues of direct concern to local practitioners.
In Scotland, the area professional committees have similar statutory functions. They advise health boards on the provision of services but do not deal with the remuneration or conditions of service of individual practitioners.
Many LRC’s have been involved in setting up local performance procedures and have members with considerable experience of working with practitioners in difficulty. LRC’s can provide pastoral support to a professional colleague in distress, as well as an expert view to the PCO on the nature of problems raised (including contractual aspects). Formal separation of these roles can be achieved by the involvement of more than one local committee member if necessary. LRC officers, as registered practitioners, have a professional obligation to protect the safety of patients.
Some PCOs have LRC representation on local performance ;groups, either as full members or with observer status. This should help to give practitioners confidence in the performance procedures operating within the PCO’s area.
Where a LRC becomes aware of a concern about a practitioner which the PCO is not et aware of, the LRC should ensure that it is raised for handling through local performance procedures and, if appropriate, with the national professional regulator.
In England and Wales, the Dental Reference Services (DRS) employs dental reference officers to monitor and advise on treatment quality. There are similar arrangements in Scotland provided through the Scottish Dental Practice Board (SDPB) and the Scottish Dental Reference Service. Northern Ireland has a Referral Dental Service.
Following a PCO request, clinical appraisal of a practice will normally involve an interview and clinical examination of patients, a review of the practitioner’s clinical records and radiographs, and a discussion (with immediate feedback regarding the appraisal) with the practitioner. On completion of the visit, a formal written report is forwarded to the dental lead at the PCO about the outcome of the appraisal. A copy of the report is also sent to the contractor.
Healthcare regulators monitor NHS organisational performance rather than individual practitioners and it is to these regulators that PCOs should be able to demonstrate appropriate and effective local performance procedures:
Care Quality Commission in England
Regulatory and Quality improvement Authority (RQIA) in Northern Ireland
Healthcare Inspectorate Wales (HIW).
There is not at present an equivalent monitoring body in Scotland. The Scottish Commission for the Regulation of Care in Scotland covers social care but its remit excludes monitoring NHS healthcare. NHS Quality Improvement Scotland (QIS) currently sets standards for secondary care. These organisations will be restructured in 2011, when Healthcare Improvement Scotland and Social Care and Social Work Improvement Scotland will take over.
GP performance procedures have been the subject of ongoing political and professional debate for many years. These are some of the key documents which have contributed to current thinking in NCAS and elsewhere.
Department of Health. Maintaining Medical Excellence. London, DH. 1996.
The ‘Calman’ Inquiry, with the terms of reference ‘to review guidance and procedures relating to GPs whose performance appears to fall below acceptable standards and to make recommendations to the Secretary of State for any necessary changes and further work needed.’
University of Sheffield. Measures to assist GPs whose performance gives cause for concern. University of Sheffield, 1997.
This report, commissioned by the Department of Health, addressed issues of principle, definition, identification, diagnosis, intervention, resourcing and evaluation and also suggested a practical management framework for dealing with performance problems.
Department of Health. The New NHS: modern, dependable. London, DH. 1997.
A statement backing the idea of clinical governance and requiring practitioners to accept responsibility for developing and maintaining standards in local NHS organisations.
Department of Health. A first class service: quality in the new NHS. London, DH. 1998.
The Department of Health reinforced primary care trusts in England by giving them a statutory duty to ensure quality of care through better clinical governance. A systematic approach to monitoring and the development of clinical standards were seen as essential.
General Medical Council. Good Medical Practice. GMC. 1998
This ground-breaking document described the principles of good medical practice and standards of competence, care and conduct expected of all doctors, regardless of specialty. It has been regularly updated since first publication.
Department of Health. Supporting Doctors, Protecting Patients: a consultation paper. London, DH. 1999.
The Department of Health argued that procedures for detecting and dealing with poor clinical performance were fragmented and inflexible and proposed a new framework. The aim was not only to provide better protection for patients, but also to facilitate the earlier recognition of doctors with problems and provide effective support for them.
Department of Health. Assuring the quality of medical practice: implementing Supporting doctors protecting patients. London, DH. 2001.
The Department of Health defined new approaches to the handling of concerns about doctors and set up the ‘National Clinical Assessment Authority’ which later became NCAS.
British Medical Association and Royal College of General Practitioners. Good Medical Practice for General Practitioners. 2002.
A joint publication from the British Medical Association and the Royal College of General Practitioners which interprets the GMC’s performance requirements in the specific context of general practice, specifying points that would describe an excellent and an unacceptable GP. Also regularly updated since first publication.
University of Sheffield. Primary Care Trusts and GPs whose performance gives cause for concern. University of Sheffield, 2002.
Another report from ScHARR, University of Sheffield, commissioned by the NHS Executive, which gave primary care trusts in England a framework within which to develop their own local performance processes.
National Clinical Assessment Authority. Handbook for prototype phase. NCAA, 2002. (Out of print)
This was NCAS’ (formerly NCAA) first handbook for general practice, defining an assessment process but also suggesting how assessments might support local procedures.
*National Clinical Assessment Authority/National Clinical Assessment Service. Handbook. NCAA/NCAS, 2004. (Out of print)
This replaced the 2002 handbook, describing generic processes for both primary and secondary care. Regularly updated since, a new edition is due in 2010.
*National Clinical Assessment Authority. Understanding Performance Difficulties in Doctors. NCAA. 2004.
This document presents research on the reasons why a doctor may come to under perform. Includes the impact on performance of physical and psychological health, cognitive impairment, personality, attitudes, organisational culture and teamwork..
Cox J, King J, Hutchinson A and McAvoy P. Understanding Doctors' Performance. Radcliffe Publishing Ltd. 2005.
This book provides more detailed information about factors that may contribute to doctors’ performance difficulties.
Department of Health. Good doctors, safer patients: Proposals to strengthen the system to assure and improve the performance of doctors and to protect the safety of patients. London, DH. 2006.
Report of a review of medical regulation undertaken by the Chief Medical Officer for England.
*National Clinical Assessment Service. Back on track. Restoring doctors and dentists to safe professional practice. Framework document NCAS, 2006.
Proposals from NCAS and partner organisations to structure remediation planning after NCAS or other assessment and introduce more consistency across the country and between sectors.
The Stationery Office. Trust, Assurance and Safety – the regulation of health professionals in the 21st century London, The Stationery Office. 2007.
A white paper setting out plans to improve quality of care. In chapter 3 it deals with ways to tackle concerns about healthcare practitioners locally.
* These documents can be found at NCAS Publications.
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 firstname.lastname@example.org.
This is a general guidance document but NCAS can be contacted at any stage for advice about the handling of a specific case.