This is a report of The St Paul RCGP Quality Unit's second conference 'Managing poor performance in general practice' held in conjunction with the National Primary Care Research and Development Centre on the 3rd July 2001 in Manchester.

The day was partly a meeting of minds, partly a launch of the St Paul/RCGP Toolkit .

The Toolkit is a work in progress and participants were asked for feedback and suggestions about the way it should develop.

The day was a mixture of lecture-type presentations and group discussions. Yours truly had intended to go merely as a delegate representing the NASGP, but after a panicked phone call, ended up facilitating one of the workshops (see our report below).

Formal presentations took up the morning, with speakers detailing how poor performance had been tackled in their areas.

Prof. Martin Roland (a member of the Manchester Poor Performance Review Panel), spoke of the panel's experiences over the last 3 years. Often there is much information about suspect performance available, if only on in informal basis. The need is to bring that info together so the big picture is seen. However, this is not usually the trigger for the panel to become involved, merely what comes to light once they do so. He also spoke of what he felt could make the process better/fairer; clinical skills review, health assessment of the doctor concerned.

Dr Steven Wright (medical adviser Rotherham Health Authority) outlined the approach taken in his locality. He had been an early advocate of performance indicators (PI) - from routine information already held at the HA. These indicators had consistently shown where there were areas of concern in performance and where further investigation was required. He finished by saying that PI weren't the whole answer - merely a pointer - but the profession couldn't simply write them off as a managerial imposition.

Dr Helen Josebury (Senior Clinical Lecturer, University of Sheffield) presented a review of Trent HA ways of tackling poor performance. Again the use of PI only served to draw the eye to possible areas of poor performance, they were not the be-all and end-all of the review of practice. Practice visits to doctors causing concern tended to be supportive rather than confrontational. She stated that many HA worried that they might not be 'getting it right' - there were no nationally accepted standards or protocols to work to. HA had expressed the hope that this was an area the NCAA would tackle.

Dr Rosemary Field (on secondment to NCAA) outlined what the NCAA hoped to achieve. Perhaps more importantly, she asserted that the NCAA was not the 'answer' to HA problems in tackling difficult cases. It would only become involved where local remediation had failed, it had no disciplinary powers itself. However, her presentation did seem to imply that as a national body, it would indeed be collating 'best practice' in how poor performance was tackled and then facilitating the roll out to all HA. On a very relevant to NPs note, Rosemary was adamant that local procedures should cater for all GPs, not just principals/practice-based ones. NPs would not simply be referred direct to the NCAA. Richard and I are meeting with Tim Wilson and Rosemary in September on how poor performance in NPs should be tackled.

After the workshops we returned for more lectures.

Dr Jamie Baharami (Director of Postgraduate GP Education, Yorkshire) shared with us the yet to be published results of a review of those cases of remediation/retraining referred by the GMC and HA that had been dealt with by the deaneries. Doctors 'dealt with' by the GMC in this fashion resented the GMC decision and by extension the Deanery. They didn't agree they needed retraining and didn't want anything to do with the deanery. They also had very unrealistic expectations of what timescale was involved - often wanting overnight, if not instant, action. On the other hand, deaneries were ill-equipped to deliver in some cases and disagreed with the GMC's decision in others. Outcomes of retraining were not always clear and there was often a lack of feedback on progress from the GMC. Those cases referred by HA had on the whole been tackled locally, but needed 'extra' help such as, educational expertise, mentoring or appraisal.

Problems encountered in the referral process were generally due to a lack of information and a failure to communicate by the referring body.
The review highlighted the need for an explicit protocol for dealing with such doctors, including assessment and ongoing development, along with an individual learning plan which showed evidence of progress.

Dame Lesley Southgate (Elle Presidente and head honcho of the GMC performance procedures) outlined details of those doctors passing through the Fit to Practice procedures in its first eight years (I hadn't realised it had been going on for so long). 27 doctors had gone through - 7 of which were deemed not to be under-performing. Recurring themes in these cases included poor local resolution and documentation, failure of local complaints systems to deal with angry, grieving patients and relatives and that difficult, awkward doctors are not necessarily incompetent.
Indeed, competence and performance correlates poorly with assessment of relationships with patients and she wondered if in future information should be gathered direct from patients locally. The overwhelming finding is that peer review is the most powerful part of the process.
And finally, the General Practice Tzar, David Collin-Thome, spoke on appraisal. Incidentally, this was one of the men who influenced my decision to be a GP - I did my undergraduate general practice firm with him at his Runcorn practice - an experience I thoroughly enjoyed. But that's another story.

I was pleasantly surprised.

David completely agrees with the concept that appraisal must be developmental and formative, not managerial and punitive. Guidelines on how GP appraisal should be done will be developed in agreement with the RCGP and GPC. He hopes such a system will help consolidate developmental procedures and reduce duplication.

Appraisal should be a management-supported, locally driven, annual, two-way performance review, involving economy of effort and therefore overlapping Revalidation. He hoped such local assessment procedures would be developed and led by the Deans and Tutors in partnership with Primary Care Organisations.

On the specifics of appraisal, it should be:

• practice-based, but (in answer to my query) he felt that NPs should easily be accommodated by local systems - I couldn't draw him further on this.
• take half a day per appraisal but be well prepared
• resulting in a confidential output - to the GP and the appraiser. However, he did postulate that it might be shared with PCOs at some future date.
• show evidence of improvement against the GP's gaols as stated in their PDP; and be achievement based. Such goals must be realistic and set by individual doctors in the context of their own practice, unrealistic goals are often set as an excuse for poor performance.
• an internal process within an organisation (in this case the NHS), not an external policing process.

Punitive, undemocratic, bureaucratic models of appraisal don't work.
When asked what he felt the relationship between appraisal and the GMC performance procedures should be, he replied that a direct link would be disastrous - GPs would lack confidence in the process.

He also acknowledged that training of appraisers was paramount - good active listeners would be excellent candidates - and that the resource implications dictate that appraisal would be introduced on a gradual basis.

What did I learn?

A lot about what has been tried in the field of tackling poor performance in the past - and what works. A strong 'can do' attitude to ensuring the processes become universal and inclusive. Desire to make the systems 'work' for NPs and a willingness to work closely with the NASGP to achieve all this.
I'm looking forward to the September meeting; we live in interesting times.

Tina Ambury
Deputy Chair NASGP
July 2001

TACKLING POOR PERFORMANCE AND CREATING THE CULTURE

Facilitator: Dr Tina Ambury
Reporter: Dr John Waring

The remit of the workshop was outlined by the facilitator - to bear the Toolkit in mind whilst discussing the topic - before introductions from group members were made.
Participants had a mixed involvement in performance review; GP & nurse clinical governance leads/co-ordinators/managers and a Primary Care Development Officer from PCGs, a GP from a research practice and an LMC GP.

The issue of 'culture' raised mixed feelings;
· concerns from GPs ref. 'them & us' - those doing the review being the 'them'
· one GP used the term "vicious and nasty" with regards to the prevailing atmosphere surrounding performance review

One participant told how her PCG was using identifiable data when comparing GPs' and practices' performance, with the full agreement of all concerned - some group members were sceptical that this would be beneficial due to the 'naming and shaming' atmosphere it could generate. However, the member concerned felt that the process was transparent and allowed 'real' comparisons to be made. A concern was raised that this might lead to polarisation of large 'v' smaller practices. Another participant likened this to the development of out-of-hours co-operatives allowing peer review of practise across practice boundaries. This in turn had engendered a willingness to be more open and was part of the background of change in the culture that was already occurring.

The influence of PMS contracts - where quality assurance targets are built in - were seen to have a role in 'tying down' practices to stated quality goals. The group heard that one participant's PCG had become completely PMS and another's was at least 60% PMS. Would this improve quality and performance? There is certainly an implied (if not open) threat in the NHS Plan that single-handed practices will have to become PMS.

The issue of which culture needed to change was discussed and even touched on the possible dismantling of the NHS as a whole. Certainly, patients' expectations and demands on performance need to be challenged. Are GPs bad? No, most are trying very hard to provide a good level of practise. Expectations on GPs are high; clinical role, paperwork, managing practices etc. - are they too high? Why should a GP be able to do everything well?

The "no-blame" culture that the profession feel is necessary for performance review to be acceptable certainly seems at odds with what the government is actually saying; one participant spoke of his experience of a visit from CHI early in that body's life. He certainly felt bruised and far from supported at the time.

The old nugget of 'measuring the immeasurable' was debated; are those things that can be measured actually useful to the individual doctor as indicators of performance? The group took the view that some doctors' use of this argument to dismiss the 'evidence' could actually be a smokescreen; do underperforming doctors really not know that they are underperforming and lack insight, or are they in denial? Acknowledgement by the individual that there is a problem to be addressed is an important step towards tackling that problem.

Several participants spoke of how clinical governance visits - though time-consuming and very labour intensive - were proving helpful in providing feedback to practices. Achievement often leads to more achievement. Supportive feedback is a powerful motivator for change, especially done in a facilitative (not humiliating) manner. Any problems that were found to be resource-driven needed a speedy response, which helped practices view the whole process as supportive rather than punitive - a crucial factor if performance review was to be accepted by the profession. However, that process was a gradual, ongoing one rather than merely a spot-check visit.

Participants expressed concern that forthcoming changes to NHS management with strategic health authorities might cause some of the gains in changing the culture to be lost; it was felt they would be too big to influence change on a practice or individual level. Also, there were fears that they might even stifle locally generated change. Such local 'ownership' is a vital empowering tool.

Two participants spoke of their PCG's use of the RCGP QTD scheme in delivering the clinical governance agenda. There was surprise at how the same scheme could be interpreted in two very different ways. However, both felt the scheme was useful in engendering a culture of change geared towards gradual improvement. Team 'weaknesses' were identified, using Quality Team Development QTD, by the teams themselves. The developmental plans resulting from this process became an ongoing marker of that team's progress towards better performance. In one PCG (Harrow) the PCG 'owned' the plan. In the other (Wyre) the practice retained ownership. Several other participants expressed an interest in finding out more about QTD. QTD was seen to be a pro-active way of identifying potential underperformance, rather than relying on incidental findings of actual underperformance.

A call for a professional mediation service was made (akin t ACAS); systems rather than individuals were often the root cause of underperformance and there needs to be an organisational approach to tackling the problem. The issues of resources (time, people, money), reimbursement and equity were all aired by the group.

The NCAA was seen as a potential 'good thing'. A possible role it could adopt is one of collecting evidence of best practice in dealing with underperformance issues and enabling the sharing of this evidence across the UK. The group was however a little sceptical that it could deliver.

The group acknowledged that all the work done so far was aimed at promoting good practice - there was a very real need to tackle bad practice. However, participants felt that this was actually beginning to happen and were optimistic about progress on this front being made in the near future.

Appraisal was also viewed optimistically, so long as the profession got behind the process, which required it to be supportive, educative and formative - not punitive.

The 'Toolkit' was seen as a good starting point;
· it provided a useful framework
· it was quite reassuring!
· it generated lots of questions about tackling underperformance
· and was successful in sharing the current body of knowledge effectively.

Back to main report

The NASGP Newsletter is kindly funded by an educational grant from the Medical Protection Society

© NASGP 2008.