Handling poor performance in General Practice

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Handling poor performance in General Practice

• Helen Joesbury

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Part 1
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What is meant by poor performance?

• One who does not perform as an average doctor
  would do
• When there is concern about the doctors ability
  to provide a safe service

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Legal and Policy Framework

• Medical Professional Performance Act 1995
• Delivering the Future 1996
• Human Rights Act 1998
• Supporting Doctors,Protecting Patients 1999
• Shipman enquiry
• Whistleblowing in NHS policy 2003
• Good doctors, Safer patients 2006

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Practice or Individual

• Overlap between poorly performing practices and
  performance in individual clinicians
• Rarely due to malice fraud or criminality

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Good practices

• Good policies
• Motivation
• Information management
• Internal communication
• External inspection
• Training practice
• Quality awards

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Slipping performance

• Clarity about standards
• Limited contact with PCT
• Failure to use modern information systems
• Weak understanding of clinical governance
• Poor practice management

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Why does it matter?

• Deaths from medical errors
• Increased complication rate from chronic disease
• Increased hospital admissions
• Outbreaks of potentially infectious disease
• Etc
• Majeed et al BMJ 2007 335 p916-8

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Causes

• Personal problems and ill health
• Demotivation
• Financial problems
• Poor practice management
• Poor understanding of clinical governance

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External causes

• Poor facilities
• Staff
• Premises
• Equipment
• Patient choice
• Refusal of immunisations
• Poor compliance with medication or review
• Failure to attend screening
• Or are they excuses?

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Part 2
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Performance indicators

• Not diagnostic
• Wide ranging
• Out-lyers are important
• Records are key

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Quality and Outcomes Framework
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QoF visit

• What you might look for
• Use of computer
• Summaries
• Medication linked to diagnosis
• Exception reporting

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Part 3
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Principles

• Management
• Led by senior or clinical manager
• Confidential, robust and sensitive
• Evaluation
• Local Support Panel

• Process
• Medical Model
• Define
• Identify
• Diagnose
• Treat
• Monitor

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Supra PCT Performance Advisory Group
PAG Steering Group
PCT Decision Making Group
Other PCTs
PCT Board
CG Lead
GP
Support provider
Case Manager
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Other key bodies

• NCAS
• GMC
• Healthcare Commission
• SHAs
• FHSAA
• Deaneries
• LMCs

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Resources

• National Clinical Assessment Service (NCAS)
  (NPSA Dec 2006) www.ncas.npsa.nhs.uk

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• Be familiar with and generally adhere to policies
  and procedures for handling disciplinary
  problems, fully establish the facts, and document
  the approach scrupulously.
• Avoid precipitate action on apparent disciplinary
  matters things are often not always as they
  first seem.
• Remain non-judgemental - do not be drawn into
  expressing preliminary opinions or making
  gratuitous observations.
• Beware of manipulation by those who have axes to
  grind.
• Never opt for a quiet life by avoiding dealing
  with problems - this may be to the serious
  detriment of patients or the effective
  functioning of a clinical department. "

(Sir Liam Donaldson writing in the British
Medical Journal 1994 3081277-82.)
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