I could not locate the name of the author to whom full credit should go. Any claimers welcome on the comments section. Thanks.
The Management of Concerns within Health Care Systems in the Context of Total Quality Management
Case Study: Dr Nancy Olivieri 6
Defending Medicine. 7
United Kingdom.. 8
Supporting Doctors, Protecting Patients. 9
The Problem.. 9
Identifying problems with a doctor’s practice and putting things right 14
Clinical Governance. 16
Subsequent events. 17
NHS Guidances and Directives. 18
Doctors' and dentists' disciplinary framework: introduction and explanatory note. 18
Action when a concern arises. 19
Restriction of practice and exclusion from work. 20
Guidance on clinical academics. 22
National Clinical Assessment Authority (NCAA) 23
NCAA Toolkit 23
NCAA Research. 28
Auditor General’s and Committee of Public Accounts Reports. 33
Case Study 1: Wendy Savage. 34
Case Study 2: Bristol Royal Infirmary. 37
Case Study: Walker Inquiry. 43
Appendix I: Selected Quotations. 46
Appendix II: Supplementary papers. 51
Recently, and understandably, there has been a great deal of public interest and concern about a series of closely related issues, regulation of health professions, medical errors and patient safety, and continuing quality improvement. Regulation and evaluation should meet a dual role, that of protecting and reassuring the public as to the maintenance of standards, and reassuring and supporting the professions as to the quality of care delivered.
An aspect of this that has been relatively overlooked and not yet integrated well into the overall picture has been the way in which health care systems handle problems, all too often by dealing with the aftermath and not the cause.
This paper attempts to summarise our current understanding of these issues, illustrated by what we know about the evolution of concepts in selected countries, and by selected case studies from those countries.
In Canada, despite the fact that performance evaluation and correction is appropriately embedded in the rhetoric of patient safety and quality management, no formal national approach to this has been addressed, being left instead to Provincial licensing authorities.
2002 was a watershed year for patient safety with the report of the National Steering Committee on Patient Safety. In ‘Building a Safer System’ we find reference to the need to “Develop and implement responsive patient-focused programs for the receipt, review and management of concerns within health-care organizations.”
The document also addresses the need to “Develop a greater focus on improvement through education and remediation, vs. blame and punishment, in legal, regulatory and human resource processes”.
In addressing the overall question, one of five working groups was assigned to the legal and regulatory questions: ‘How can the manner in which the regulation and monitoring of health-care professionals and their institutions, and the legal systems, improve safety?’
One of the incidental recommendations was the rejection of the term ‘medical error’ as being associated with a ‘culture of blame’. The overarching conceptual model saw the legal and regulatory processes as but one ingredient of an integrated system, which included measurement, evaluation, education and communication. However the emphasis in this group was on tackling a legal and regulatory environment that perpetuates fear of blame and litigation, rather than on monitoring and correction.
Although recommendation 5 focuses on the management of concerns, it is from the vantage point of complaints from patients and families (patient focused) about adverse events. However it recognised the need for an open culture and resolution in contradistinction to an adversarial system based on punishment and isolation. It noted that the current system does not encourage discussion of issues, due to a perceived burden of ‘perfection’. The preferred culture is described as one of safety. However in terms of ‘non-punitive’ reporting, the emphasis would appear to be on the reporter rather than on the reported, which seems unbalanced.
Regulatory bodies are seen as involved in a search for and need to cull ‘bad apples’ rather than stressing education and remediation. The preferred system is based on continuous improvement and learning (sometimes referred to as a culture of learning).
The second recommendation dealing with legal and regulatory issues is number 8. In this, regulatory bodies are still seen as having the responsibility for evaluation and addressing competence and performance, and correction of ‘incompetence’. Although restrictions on practice and withdrawal from practice are visualised as remedies, the preferred approach is stated to be identification and remedy of underlying problems.
‘Building a Safer System’ recognised the potential for devastating consequences to the individual resulting from hearsay or premature conclusions based on inadequate information and urged effective peer review.
The outcome of this, as in many other countries, was the establishment of the Canadian Patient Safety Institute in 2004.
Little is known about the management of concerns and complaints in Canada, other than a few well publicised cases, usually at the level of Provincial College proceedings, often involving sexual offences or fraud. The CMPA has a database of legal actions and disciplinary proceedings. There has been debate as to whether this should be made available for research. CMPA records reveal 200-300 cases per year involving physician’s hospital privileges.
Canada has had its own version of the Bristol Royal Infirmary (see Case Study) paediatric cardiac surgery tragedy in Winnipeg, and similar issues around accountability and blame have come to light. As a CMAJ editorial at the time, states;
“It is always easier to find a scapegoat than to change the culture of a working environment. But we must find the resources and muster the personal resolve to look at what we do in a systematic way, prospectively as well as retrospectively, expecting errors and developing non-blaming mechanisms for preventing them.”
A framework for physician appraisal has been in existence in Canada since 1993 in the capacity of the Federation of Medical Licensing Authorities of Canada and its Model for Monitoring and Enhancement of Physician Performance (MEPP). The underlying philosophy being changing the emphasis from blame to quality improvement and learning. A series of workshops on these topics (the Aylmer Workshops) were held over 1994-2000. One of the limitations is that these concentrated on the role of Provincial licensing authorities as opposed to health care systems internal disciplinary procedures.
Regional assessment programmes have been developed in Alberta, Ontario and the Atlantic (Atlantic Provinces Medical Peer Review Program), established in 1993. A related programme in Alberta is the Physician Achievement Review programme which seeks feedback from health care consumers and colleagues about physician performance. Nova Scotia started its own peer assessment process at the beginning of 2005 (NSPAR), based on the Alberta model. At present this is limited to primary care.
Meanwhile Provincial Colleges are actively exploring alternative less adversarial or punitive approaches to resolving complaints.
“The College approaches complaints about physicians as problems to be solved.
A complaint may provide the opportunity for a physician to change behaviour, or to improve some aspect of practice. In some instances…assessment and retraining may be required. Our experience is that the best outcome happens when the physician is a willing participant in the complaint process. …
We prefer to work with the physician to identify the problem and to work towards a solution. We believe that the chances of long-term success with this approach are much higher than if disciplinary action is taken – action that may, in fact, be counter-productive to creating a positive change in physician behaviour.”
And moving from a reactive complaint process to a preventative approach
“We are changing the way the College currently monitors the performance of physicians. Specifically, we are moving from a reactive complaints and discipline model, to one which seeks to better guide the profession and prevent practice problems. The College wants to help physicians before any bad habits become entrenched into daily practice.”
Case Study: Dr Nancy Olivieri
The inquiry which has created the greatest public interest in Canada is the Olivieri Report.,, A Toronto paediatric haematologist found herself in conflict with the commercial sponsor of a trial she was conducting. She was dismissed from her position, referred to her hospital’s internal disciplinary committee (Medical Advisory Committee), and then referred to the College of Physicians and Surgeons of Ontario’s Disciplinary Committee for misconduct, who cleared her of the charges. Ultimately she was reinstated, and her main accuser was actually the one who was ultimately disciplined by the College.
The case raised many questions about the relationship of institutions, investigators, research oversight and commercial interests, about academic freedom, and the interaction between universities and health care organisations.
In its recommendations the Independent Committee of the Canadian Association of University Teachers addressed the need for clinical academic staff to have equal access to grievance and arbitration procedures as their non-clinical colleagues, and that Medical Advisory Committee and Board decisions be subject to such procedures. It also addressed the need for due process in disciplinary procedures and for the above to be incorporated into affiliation agreements between universities and teaching hospitals.
In an editorial at the time, the Canadian Medical Association Journal recommended that in future such matters be investigated by independent committees. The many issues raised by these events continue to ricochet not only in Canadian but international medical circles, and even a novel.
“In failing...[her] when she needed them most, it is now clear that some members of the University’s Faculty of Medicine heard her muffled cries of academic freedom from the back room, yet their response was to serve another round of drinks and turn the music up louder.”
In the wake of the Olivieri affair, CAUT’s Academic Freedom Committee set about addressing the broader issues of the interface between universities and teaching hospital in dealing with clinical academic staff. A position paper on joint appointments was released in 2002 enshrining the relevant recommendations from the Olivieri report.
At the same time a Task Force on Academic Freedom for Faculty in University-Affiliated Health Care Institutions was established to undertake a wider inquiry and its report was released in November 2004.
In essence this noted widespread vulnerability and abuse, and in particular the use of termination and control of revenue to enforce social and academic acquiescence. It again stated that clinical academic staff must have the same rights and privileges as non-clinical academic staff. In particular it noted the need for security in terms of employment and income, and the triple jeopardy faced by the intermingling of university, hospital and practice plan personnel.
Disciplinary bylaws usually lack access to natural justice and procedural fairness, in striking contrast to grievance arbitration.
While a number of countries including the United States, Australia, New Zealand and the UK have undertaken similar initiatives, only the UK has undertaken a radical overhaul of its procedures for dealing with concerns in the health care system.
These reforms followed a series of well publicised events and inquiries, including the events leading to and following the Beaumont (London 1986), Griffiths (North Staffordshire 2000), Ritchie (Kent 2000), Alder Hey (2001) and Kennedy (Bristol 2001) inquiries. Another stimulus was a report of the Committee of Public Accounts of the House of Commons in 1995. These various inquiries and reports made sweeping recommendations for reform.
Concerns at an administrative level surfaced in 1994 with Donaldson’s analysis of and description of the inadequacies of the existing system. He described the experience of one Health Authority where serious allegations arose in 6% of the workforce, delineating the areas of concern and outcomes. Approximately half of the doctors returned to the workforce. Suspension was rarely used, retirement being used more commonly to resolve intractable problems. Referral to the General Medical Council was also rarely used. Donaldson pointed to proposed reforms by the Council which would shift the emphasis from punishment to remedy.
Another pressure on the system came from the Society of Clinical Psychiatrists which formed a study and support group on suspensions and suspended doctors, and produced two reports (1990 and 1999) describing the practice as ‘shocking’ and ‘a blot’. They showed that less than a third of cases involved allegations of professional incompetence and that only 10% of allegations were found to be justified. They commented on the severe health problems that ensued in the suspended physicians. Tragically three of 171 suspended physicians died as a result of the suspension.
Supporting Doctors, Protecting Patients
In 1999 the English Department of Health released a consultation paper: ‘Supporting Doctors, Protecting Patients’, under the framework of improved Clinical Governance (see below under implementation) and quality improvement (similar papers followed in Scotland and Wales).
The paper recognised the ‘legalistic inflexibility’ of the existing system of dealing with concerns about individual performance, and set out to develop a concept that was ‘supportive and preventive’. In doing so it recognised that when problems had come to light in the past they often revealed chronic system failures, and therefore sought to be proactive rather than reactive. Amongst the recommendations were that assessment should be performed at a distance, should not be precipitate, and should be beware of those who seek to create inaccurate scenarios.
Interestingly, while identifying well documented failures it only briefly alluded to instances where subsequent inquiries revealed that the alleged concerns had no substance, like the Beaumont inquiry. A subsequent report by the National Audit Office (NAO) has addressed this.
Three essential components were identified; prevention, recognition, and correction. These were depicted as ‘an alternative to disciplinary action’. It also recognised the need to move in tandem with professional associations and licensing authority (General Medical Council), and professional self-regulation in general as part of a framework of the ‘delivery of quality patient services”.
Amongst failures identified in the existing systems were local solutions without system-wide approaches incorporating learning, and a failure to incorporate Human Resources principles, resulting in unfair, costly and cumbersome procedures, instead of providing a transparent atmosphere for discussing performance and concerns, and the provision of professional development and support. It was hoped that this approach would greatly diminish the number of disputes, and actual incidents of patient harm. All too often performance issues were seen as ‘punishable offences’.
A recurring theme running through all these inquiries and reports was that of system wide failure;
“Nevertheless, sometimes the failure may not be wholly attributable to one individual but may be symptomatic of organisational malaise. In determining remedial action, organisational factors need to be taken into account.”
At that time it was estimated that about 6% of the senior workforce were having problems, and about 5/10,000 (0.05%) doctors were under suspension. Doctors at every stage in their career can exhibit significantly higher levels of psychological disturbance than those found in equivalent professional occupations. Health problems range from anxiety, emotional exhaustion to clinical depression and suicide. In some groups these problems are associated with addiction (e.g. alcohol and drug misuse) and with a lower standard of patient care. Moreover, many doctors are reluctant to admit that they are sick, and may self-prescribe. Many physicians do not have regular family doctors. In 1998 a Nuffield Trust survey found that 25-50% of hospital workers exhibited psychological disturbance. Similar figures have been reported amongst cancer workers in Canada,,,.
Therefore in conjunction with the new procedures being recommended would be measures to reduce stress in the workplace.
While the General Medical Council (GMC) had procedures in place for dealing with performance concerns, it was considered that referring all cases was impractical due to ‘the volume of such cases’ and that furthermore this would represent ‘an inappropriate abrogation’ of the health authorities’ ‘proper role as employers’ as well as introducing impractical delays.
Cumulative costs to the National Health System in England in 1999 of suspensions lasting more than 6 months was estimated as over £2,500,000.
The report was also acutely aware of the potential for abuse of the performance review system by unwarranted allegations, and recognized the considerable damage that can occur. Whether the allegations were warranted or not the report recognized the debilitating effect of existing procedures including cost, morale of clinical staff, and burden on administrators. Perhaps most significant of all ‘the opportunity for re-education or improvement is then often permanently lost.’
In developing a quality framework the report recognized that key elements must include the development of agreed standards and a monitoring system to ensure that the standards are being delivered. Theoretically this should result in early detection in changes in quality at various levels of the organizational structure and the opportunities for early correction. It emphasized the need for all levels of organizational structure to take responsibility for quality and performance within their area of responsibility. This is in contradistinction to less efficient systems based on complaints and incidents.
Mechanisms to achieve this include Continuing Professional Development (CPD) and Clinical Audit. Inherent in this is appraisal, both self and peer originated. It is stressed that
“Appraisal is a positive process to give someone feedback on their performance, to chart their continuing progress and to identify development needs. It is a forward looking process essential for the developmental and educational planning needs of an individual. Assessment is the process of measuring progress against defined criteria… It is not the primary aim of appraisal to scrutinise doctors to
see if they are performing poorly but rather to help them consolidate and improve on good performance aiming towards excellence..”
This in turn demands that methods of appraisal be valid and understood, and that those involved in appraisal be adequately trained in its execution.
In proposing remedies as to how concerns when raised are dealt with, the report recommended an external source of support and assessment rather than highly variable local procedures, to provide a more neutral environment, free from acrimony. In particular it was stressed that a new mechanism must be integrated into the procedures of professional associations.
Specifically it was recommended that a number of Assessment and Support Centres be established to impartially advise employers on procedure and to provide an ‘environment supportive of the doctor undergoing assessment’. While it was envisaged that any new system would replace traditional disciplinary measures, it was also realized that some conduct issues (e.g. theft) would be more appropriately handled locally. Similarly although it was suggested that performance issues be handled by the Centres in liaison with the GMC, some issues of severe dysfunction would require early intervention by that body.
In terms of the operating details, it was suggested that where concerns arose ‘for which there was no immediate solution’, referral be without stigma, and occur without delay. Mechanisms would also be in place for self referral where appropriate.
In dealing with the issue of stigma it was stressed that ‘referral is not a disciplinary act. It would be exceptional for a doctor to be suspended prior to referral.’
It was proposed that suspension be reserved for
(i) physicians refusing referral
(ii) physicians referred back with intractable problems
(iii) imminent danger to patients
(iv) internal disciplinary procedures
Centres would judge the appropriateness of the referral, assess the situation and issue recommendations. Recommendations would be either;
(i) a return to practise, reassured
(ii) return to practise with monitoring by specific criteria
(iii) re-education or retraining and reassessment,
(iv) referral to the GMC for registration issues (imminent danger),
(v) referral for treatment,
(vi) referral back to employer, considered serious and intractable (termination or retirement)
There would also be scope for referral of the problem to the authorities because of serious organisational implications. In practice this referral was to be the Commission for Health Improvement. Implementation would remain with the referring health authority. And there would be a right of appeal. The centre would coordinate retraining or treatment. Doctors would remain on full pay.
It was hoped that this process would reduce the need for legal involvement, and allow for the development of expertise in assessment.
The Department of Health tabulated, summarized and circulated the nearly 400 responses to the Consultation Paper. Responses were favourable in principle but differed on details. Respondents thought that the process should be more patient centred. It was felt there was a need for a separate process for teaching hospitals. There was strong support for making the process part of Continuing Professional Development, and not part of any disciplinary process. It was felt that assessment in the workplace itself would be useful in order to separate system failure from performance failure. (Some comments from those responses are appended below)
Release of the responses was accompanied by an implementation paper incorporating the consultation process. It appeared in the wake of a number of initiatives to develop standards and monitor performance of the NHS overall, including the establishment of a Commission for Health Improvement (1999), subsequently subsumed into the Healthcare Commission (2004), and the 1998 publication of ‘A First Class Service: Quality in the NHS’. Another source was ‘An Organization With a Memory’ (2000) which identified that the system as a whole was failing to learn from adverse events and near misses in individual institutions, and led to the establishment of a national reporting system.
A further concept that was being developed was that of Clinical Governance. Amongst the provisions of this programme was the idea ‘that all clinical staff take an active part in reviewing the quality of the services they provide and in planning ways of improving them.’. Governance was based on the essential elements of clinical audit, the use of evidence-based practice, continuing professional development, risk management, early identification and remedy of performance and active working with patients and service users’. This concept is discussed in greater depth in the next section.
The report was therefore framed very much in the overall context of establishing and maintaining high standards. The work of the Commission for Health Improvement (CHI) had already indicated that both quality and the mechanism for ensuring high standards varied widely.
This report also launched the new authority, the National Clinical Assessment Authority
to oversee the system. The foundation of the new system was Continuing Professional Development (CPD), appraisal and audit. This was seen as an inherent component of the recently introduced 5 yearly revalidation programme of the GMC.
In accordance with the guiding philosophy of support, a Clinical Governance Support Team was created to assist implementation at the local level. A key element of Clinical Governance was the inclusion of patients in the process. Patient groups had input into the Supporting Doctors consultation.
Identifying problems with a doctor’s practice and putting things right
With regards to the specific issues of managing concerns, the final model for an assessment service was a flexible one based on local visits to minimize disruption and stigma. In keeping with lay input, the assessments “may involve gathering information on patients’ experience of the doctor’s service”.
In contrast to traditional problem solving;
“[The] Authority will endeavour to provide the doctor with a supportive environment while he or she is undergoing assessment, and will strive to be non-stigmatising. The focus will be very much on problem-solving, and where a problem with the doctor’s performance is found, …answering the question “what practical steps need to be taken so that this doctor can return to practice without risk to patients?”
Furthermore, to protect physicians a provision was included whereby a doctor would be able to seek the assistance of the Authority in situations where they were concerned that they were “the target of unjustified allegations”.
Funding would include the employment of locums as well as any expenses of subsequent education, training or supported practice.
Provision was also made for the physician to respond to the assessment before a recommendation was made to the appropriate Health Authority. It was considered that the Assessment Centre would consult widely before making its report. To improve efficiency, some of the responses to the consultation suggested a wider remit for the centers, including retraining for re-entry physicians.
An important distinction was made between ability, which references support, education and training, in distinction to conduct which addresses contract. Appropriate standards of conduct would include those of the GMC.Cited examples included sexual assault, fraud and regularly failing to turn up for a ward round or outpatient clinic.
It was realized that suspensions would still be necessary at the local level, not as “a punishment but a necessary tool to ensure quality of care and a level of protection to patients.” However it was also felt that such a circumstance should become increasingly rare. In entertaining such an eventuality it was hoped that
“Employers will need to consider whether it is in the interests of patients, the investigative process or the doctor themselves to suspend the practitioner during such investigations and to consider whether alternatives to suspension would be more appropriate. Once a practitioner has been suspended, it is essential that investigations are dealt with speedily. Employers must combine the responsibility to protect the interests of patients with that of ensuring their employees are treated fairly and with the minimum of delay.”
Other sections of Assuring the Quality of Medical Practice dealt with monitoring the quality of care provided by the system. A key element of this being the Commission for Health Improvement (CHI). CHI’s role was to review each health area on a regular basis, the frequency depending on initial findings and subsequent events, highlighting areas of concern and areas that were exemplary with the intention of the system gaining as a whole. Where serious concerns were identified, then more in depth investigations are performed. The other factor in this strategy was called Supporting Performance Improvement, in essence establishing an organizational performance assessment framework, supporting improvement and providing for flexible degrees of central control vs. local autonomy based on the indicators. A Modernisation Agency was formed to ensure dissemination of best practices, support those areas most needing remedy and training in clinical leadership and overseeing clinical governance.
The final area of reform was professional self-regulation, essentially the work of the GMC. The key element here was to deal swiftly and effectively with those circumstances where there was clear evidence of a danger to patients in terms of a doctor’s fitness to practice. This included widening the powers of the GMC to enable it to be able “to impose interim suspension or conditions quickly, to stop a doctor who represents a danger to patients from practising until his fitness to practice has been determined.”
As with other aspects of NHS reform there would be an emphasis on increased patient and public input, in addition to greater transparency and accountability. For greater efficiency the various health regulators, such as the professional colleges were brought under an umbrella of health regulation.
The NHS summed up the impacts of these changes on the profession in three ways:
“1. Competent doctors have much to gain from these initiatives – in particular the public will be reassured and give them the trust and respect their high quality practice deserves.
2. For the minority who fall short of the standard, these measures offer support and help to put things right where possible rather than a regime of punishment. The new quality programme offers far more relevant learning and development opportunities, tailored to their needs and to those of the service.
3. Only the tiny number who do not put patients at the centre of their practice have any cause to be concerned about these reforms. Unacceptable practice of this kind needs to be stopped, as the profession itself makes clear, for example in the GMC’s document Good Medical Practice.”
The philosophy underpinning and permeating the entire process is that of Clinical Governance.
“A significant first step has been the introduction of clinical governance, which
promotes a culture of patient-centred, accountable, safe and high quality healthcare delivery in an open and questioning environment.”
Based on the concept of Corporate Governance (Cadbury Report) and later extended to the public service, this concept came to light in the NHS in 1998 in Scally and Donaldson’s classic paper (see introduction to Implementation above), and rapidly became the driving force behind reform. While incorporating an earlier concept from the World Health Organisation and the literature on quality improvement. It came to mean not only defining a culture but changing a culture. The resonance is not only organizational wide, developmental and accountable but positive in connotation.
All too commonly organisations have focused on, or have been focused on, monumental failures, with little transfer of information good or bad to the totality of the system. That is, there was an absence of a commitment to learn.
What distinguishes systems that work from systems that fail is their culture. A culture of continuous quality improvement is a culture of evaluation and learning. One in which there is an open and participative working environment where ideas are shared and where positive attributes are valued, and blame avoided. Where there is a commitment to make things better. Where boundaries and hierarchies are minimized, and authority is based on wisdom rather than by virtue of appointment. Health care systems have been characterized by a lack of expectation of leadership skills, and by competition rather than collaboration.
In a learning culture neither clinical nor management decisions can be based on opinion alone. All too often innovation or failure occur in system silos. Cultures of excellence not only value their workforce but let them know they are valued.
Many of these concept and values exist in workforces but usually in a sporadic and fragmented manner rather than as a systematic philosophy and cohesive concept of management.
The main developments since the publication of Assuring Quality in Medical Practice have been the Guidances from the NHS Executive, reports from the National Clinical Assessment Authority (NCAA), and the reports of the Auditor General and the Public Accounts Committee.
In addition, the background of evolving understanding of specific inquiries has had a profound effect on thinking in this area, particularly those into the Bristol Royal Infirmary, and Dr Harold Shipman.
NHS Guidances and Directives
Current procedures for the management of discipline and suspension are laid out on the Department of Health’s website as Doctors and Dentists: Discipline and Suspension. This has evolved piece by piece and was completed in February 2005 as Maintaining high professional standards in the modern NHS: Doctors' and dentists' disciplinary framework.
This has a number of components:
Doctors' and dentists' disciplinary framework: introduction and explanatory note
This introduces the system which came into force on April 1st 2004 for dealing with issues when they arise. By that time the NCAA had managed to find alternative solutions to 85% of the suspensions requested by health authorities. It directed that the word ‘suspension’ be no longer used other than for those instances where the GMC suspends a doctor’s license. This has been replaced by ‘exclusion from the workforce’.
It set out four key elements:
(i) Appraisal and Revalidation: giving ‘doctors an opportunity to reflect on their practice and discuss, with a suitably trained and qualified appraiser, any issues arising from their work, and their development needs’;
(ii) The role of the NCCA in reducing ‘the need to use disciplinary procedures to resolve problems’;
(iii) ‘Tackling the blame culture - recognising that most failures in standards of care are caused by systems' weaknesses not individuals per se’;
(iv) ‘Abandoning the "suspension culture" by introducing the new arrangements for handling exclusion from work.
In terms of process, it recognised that the most essential element was ‘a co-ordinated process for handling concerns about the safety of patients posed by the performance of doctors and dentists’
“Whatever the source of this information the response must be the same - to ascertain quickly what has happened and the reasons; to determine whether there is a continuing risk; to decide whether immediate action is needed to remove the source of the risk; and to put in place action to tackle any underlying problem.
Under these new mechanisms, exclusion from work must be used only in the most exceptional circumstances. Exclusion of a practitioner is not a solution in itself. Furthermore periods away from work will be kept to the minimum through strong performance management arrangements which will ensure that progress is maintained and frequently reviewed. The exclusion will lapse and the practitioner will be entitled to return to work if the exclusion is not actively reviewed.”
Specific details are set out in accompanying documents.
Action when a concern arises
The first part addresses the mechanism for dealing with concerns or allegations. In doing so it explicitly recognises that the potential for harm and the possibility of error in raising such issues.
“Unfounded and malicious allegations can cause lasting damage to a doctor's reputation and career prospects. Therefore all allegations, including those made by relatives of patients, or concerns raised by colleagues, must be properly investigated to verify the facts so that the allegations can be shown to be true or false.”
A case manager is appointed, and liaison is maintained with both NCAA and GMC. In many cases NCAA involvement is informal and advisory with the intent of avoiding more formal proceedings, but includes performance assessments where appropriate. An important aspect of this is distance from the events;
“The first stage of the NCAA's involvement in a case is exploratory- an opportunity for local managers to discuss the problem with an impartial outsider, to look afresh at a problem, see new ways of tackling it themselves, possibly recognise the problem as being more to do with work systems than doctor performance, or see a wider problem needing the involvement of an outside body other than the NCAA.”
A local case investigator will then conduct an inquiry over a maximum period of four weeks to decide on appropriate action, such as referral to an outside body. One reason why the NCAA strives to avoid exclusion is that;
“because it is much more difficult to assess a doctor who is excluded from practice than one who is working.”
Restriction of practice and exclusion from work
The second part deals exclusively with those cases where some degree of patient protection is thought to be necessary, no matter how temporary. The key elements are;
(i) ‘exclusion from work is used only as an interim measure whilst action to resolve a problem is being considered’;
(ii) ‘where a practitioner is excluded, it is for the minimum necessary period of time: this can be up to but no more than four weeks at a time.’
“When serious concerns are raised about a practitioner, the employer must urgently consider whether it is necessary to place temporary restrictions on their practice. This might be to amend or restrict their clinical duties, obtain undertakings or provide for the exclusion of the practitioner from the workplace.”
“Exclusion of clinical staff from the workplace is a temporary expedient. Under this framework, exclusion is a precautionary measure and not a disciplinary sanction. Exclusion from work ("suspension") should be reserved for only the most exceptional circumstances.”
“The purpose of exclusion is:
(a) to protect the interests of patients or other staff; and/or
(b) to assist the investigative process when there is a clear risk that the practitioner's presence would impede the gathering of evidence.”
“It is imperative that exclusion from work is not misused or seen as the only course of action that could be taken. The degree of action must depend on the nature and seriousness on the concerns and on the need to protect patients, the practitioner concerned and/or their colleagues.”
“Alternative ways to manage risks, avoiding exclusion, include:
· Medical or clinical director supervision of normal contractual clinical duties;
· Restricting the practitioner to certain forms of clinical duties;
· Restricting activities to administrative, research/audit, teaching and other educational duties. By mutual agreement the latter might include some formal retraining or re-skilling.
· Sick leave for the investigation of specific health problems.”
While allowing for a maximum period of exclusion of four weeks, the directive recommends “An initial ‘immediate’ exclusion of no more than two weeks if warranted.”
Any proceedings are subject to Chapter VI of the Charter of Fundamental Rights of the European Union
Exclusions are also subject to a number of considerations. The first deals with the extent to which exclusion can fairly be taken:
“Practitioners should not be automatically barred from the premises upon exclusion from work. Case managers must always consider whether a bar from the premises is absolutely necessary. There are certain circumstances, however, where the practitioner should be excluded from the premises. This could be, for example, where there may be a danger of tampering with evidence, or where the practitioner may be a serious potential danger to patients or other staff. In other circumstances, however, there may be no reason to exclude the practitioner from the premises. The practitioner may want to retain contact with colleagues, take part in clinical audit and to remain up to date with developments in their field of practice or to undertake research or training.”
A second consideration dealt with availability for work, pay and the need for continuing professional development:
“As exclusion under this framework should usually be on full pay, the practitioner must remain available for work with their employer during their normal contracted hours….arrangements to ensure that the practitioner can keep in contact with colleagues on professional developments, and take part in Continuing Professional development (CPD) and clinical audit activities with the same level of support as other doctors or dentists in their employment. A mentor could be appointed for this purpose if a colleague is willing to undertake this role.”
While four week exclusions can be renewed, each renewal requires a formal process with identified steps to be taken at the end of 8 and 12 weeks, and no exclusion was to last more than 6 months other than where criminal investigations were involved.
In an accompanying agreement with the British Medical Association it is stressed that:
“The focus is on helping doctors and dentists to keep up to date and to practice safely, not to punish them for any problems with clinical performance.”
Subsequent parts deal in depth with the conduct of hearings and disciplinary matters (Part III), procedures for dealing with issues of capability (Part IV); and handling concerns about a practitioner’s health (Part V).
Guidance on clinical academics
Finally the universities had made representations for special considerations for academic staff based in teaching hospitals. The Follett Report arose from the Alder Hey inquiry. Drawing on a number of recent examinations of the role of academic staff, including the Nuffield Trust and Richards reports, Follett sought more explicit definition of accountability and appraisal given ‘the peculiar problems faced by clinical academics who appear to have two posts with separate employers and yet actually have a single professional job.’ It emphasises the need for a clear, harmonious and consistent framework from selection and appointment, accountability, appraisal, to the workings of any disciplinary process ‘that a clinical academic post is a single job held by a whole person, not two jobs held by two different half persons in one body’.
One of the concerns expressed from the respective priorities of teaching hospitals and universities was that ‘there is a very real risk that the pressures of service delivery … and of the delivery of education and research on universities will result in them growing further apart.’The authors noted that ‘the lines are traditionally blurred and the priorities interwoven.’ However they were very much aware that different facets of the employment responsibility were subject to different lines of accountability (clinical service, teaching and research).
Appraisal and performance review are at the heart of the document. While there was agreement on a single appraisal process it was felt this should be a joint university/hospital function. With regards to disciplinary procedures, as with appraisal, the emphasis is on managing helping and remedy, rather than formal discipline. Interestingly they suggest abandonment of older concepts of personal and professional or personal misconduct, in favour of appraisal of health, conduct and capability. It was envisaged that both parties would be intimately involved in all aspects of the process.
Amongst their recommendations in this regardwere
“that the university and NHS body must establish absolutely clear and documented arrangements for dealing with the management of poor performance and for disciplinary matters of all types…Universities and NHS bodies should jointly prepare a formal agreement on the procedures for the management of poor performance and for discipline to be followed for senior NHS and university staff members with academic and clinical duties. As a minimum, these procedures should ensure joint working in the process from the time implementation of it is first contemplated; specify which body is to take the lead in different types of case; ensure suitable cross membership of disciplinary bodies; and be expeditious.”
Although the authors touched on grievances as an issue requiring joint management they did not offer any specific recommendations. With regards to implementation, they suggested a joint action plan between government departments of education and health.
As a result of this the Department of Health developed a separate framework for academic clinical staff, which essentially recognised the rights of both parties (universities and hospitals) to be engaged in any proceedings against a member of the staff.
National Clinical Assessment Authority (NCAA)
Established in 2001, the NCAA’s mission statement includes:
“Promoting the development of local and national procedures for preventing, identifying and resolving performance problems
Assessing individual doctors and dentists, and recommending practical ways in which their performance can be improved”.
NCAA now has experience of managing over 1,000 cases (1% of the workforce). The sharing of good practice from across the system and an educational component including a web based toolkit are directed towards a goal of helping institutions ‘not to need us’. Only 6% of referrals required assessments. In 30% of exclusions in place at the time of referral, NCAA found there was no basis for this. Case studies included in their annual reports include providing support to overworked doctors, helping with interpersonal skills, improving management support of physicians, and improving recognized training deficiencies. The overall approach being getting people back to work, and resolving differences.
In 2004, a dynamic online Toolkit was developed for training and assistance of management in preventing and assessing performance concerns.
The Toolkit is based on the premise that few managers are likely to have the skills and experience to deal with these sorts of problems, and embeds them in sound management and human resources principles. Simply stated, these are that ‘management relies on persuasion rather than directives and power’ and that employees need;
“to be recruited and inducted competently, into properly-defined jobs, given regular constructive feedback, helped with difficulties, deployed to make best use of their skills and encouraged to develop further”.
The Toolkit uses many actual situations as examples and is linked to a large number of organisational, communications and management resources, and is based on psychological research into working interactions.
The Toolkit provides an excellent overview of leadership skills, team function and personal and group development. One noteworthy observation is that sound human resources stewardship in health care systems is tied to clinical outcomes.
“Team-working can improve service quality in many ways - even, in one study, reducing patient mortality. Yet caring for patients may not, on its own, be enough to make a group of people effective as a team. They need time to understand each others’ work methods and ways of thinking, away from patients and periodically outside the workplace as well.”
“Teams exist for purposes, one of which is quality assurance and performance management. The [organisation] needs everyone to take ownership of performance problems and contribute to solving them.”
The recommended approach places considerable emphasis on investing in people, coaching, mentoring and other supports. It identifies the organizational weaknesses which lead to conflict between colleagues and between clinicians and management;
“Some ‘performance problems’ have their origins simply in a clash of values between manager and clinician.”
stressing the need for clear, consistent and shared values, and suggesting constructive and proven means for resolving them, such as principled negotiation.
“It must be clear that an organisation’s values statement is not just a PR device but a practical guide to decision-making.”
The Toolkit also deals with ways of detecting problems, handling complaints and creating an open atmosphere in which concerns can be raised including situations where people who raise concerns about their own performance can be helped, and how to assist individuals with constructive feedback and guidance.
In its guide to investigating concerns it draws important distinctions between asking a set of interrelated questions. What happened?, How did it happen?, Why did it happen?, and What might stop it happening again? Investigation is defined as ‘a careful search for the truth’ including determining the relevant components of system and individual failure. Initial questions might be;
“What has happened? What do we know? What else do we need to know to understand? Who is involved? Is there a continuing risk? Do we need to do anything immediately to protect patients? Do we need to involve anyone else?”
The GMCs Good Medical Practice is suggested as a template. In considering possible causes for concerns, investigations routinely consider system problems, ill health, and victimisation and bullying.
“Differences in work style are normally expected by colleagues and tolerated. But sometimes a different style will attract criticism and come to be seen as a sign of poor performance. If the person first categorising performance as poor is influential, then others may take the same view.
Bullying can easily arise when people are intolerant and there is weak leadership. There is a large literature on bullying amongst health professionals, though this probably reflects growing awareness rather than increased occurrence… personality typing (perfectionism, self-criticism) also throws light on how colleague relationships can derail into victimisation and allegations of bullying when dominant or preferred work styles clash.”
This can be often unconscious. For instance enthusiasm can often make people around such a person feel demoralized.
Stress is placed on management having adequate training in investigative and interviewing techniques. In considering what actions might be taken, it is recognized that exclusion from work may sometimes be necessary as an interim measure in the interests of protecting public safety, but it is also pointed out that such circumstances are actually exceedingly rare.
As with the spirit of the process, equal emphasis is placed on both investigation and rebuilding.
“People with skills are expensive to replace. It makes sense to try to rebuild a career rather than scrapping probably still useful experience, skills and knowledge. ‘Rebuilding’ accommodates many possibilities – rebuilding a career path, trust, a working relationship or a pattern of clinical practice. A suitable and effective performance solution might need all four.
If there has been a suspension or a breakdown in working relationships, re-entry into the clinical team will need to be planned and implemented. This is challenging work for managers. It may seem irritatingly expensive in training costs and management time, but it should still be cheaper than scrapping and replacing.
Rebuilding is right, humane and also required by the Code of Conduct for NHS managers which puts a duty on managers to help staff ‘maintain and improve their knowledge and skills and achieve their potential’. The Department of Health’s new framework for the handling of concerns about doctors and dentists also recognises the importance of ‘seeking to tackle performance issues through training or other remedial action rather than solely through disciplinary action’. The key questions for managers are therefore:
· Can an action plan be devised which will address the concern?
· Will the clinician cooperate?
As we are defining it, ‘rebuilding’ takes in all the processes needed to return a clinician to effective and safe working. These could include:
· Job adjustment - changes of duties, grading or specialty/sub specialty
· Additional training, probably supported by the local deanery and possibly with the relevant college, faculty or specialist society also giving advice
· Behavioural coaching, possibly with guidance from an occupational psychologist or other trainer
· Planned re-entry into the clinical team: organisational re-entry as distinct from clinical re-entry.
Putting together an action plan needs care and time, if it is to have the commitment of all parties.”
NCAA experience to date has shown that behavioural as well as professional development is amenable to successful intervention;
“Behavioural coaching is used widely for successful people – grooming managers for promotion, for example. One-to-one coaching for clinicians whose behaviour is causing problems can be just as valid an investment, though that is not to rule out simpler and cheaper solutions, such as shadowing. …One-to-one coaching sessions - possibly starting weekly and then reducing in frequency – can help an underperformer work through what has been going wrong and experiment with different behaviours. An external mentor could also be helpful, who need not be a clinician.
Group or team work may also be needed, with the clinician and immediate colleagues. As with other remediation elements outcome evaluation is essential, so negotiate that as part of the coaching package.”
Recommendations for those cases that proceed on a disciplinary route, are that they follow ACAS (Advisory, Conciliation and Arbitration Service) Code of Practice. These include the following principles;
· “Use procedures primarily to help and encourage employees to improve rather than just as a way of imposing a punishment
· Make sure that disciplinary action is not taken until the facts of the case have been established and that the action is reasonable in the circumstances
· Never dismiss an employee for a first disciplinary offence unless it is a case of gross misconduct
· Give the employee an opportunity to appeal
· Deal with the issues as thoroughly and promptly as possible
· Act consistently”
“Where there appears to be serious misconduct, or risk to property or other people, a period of suspension with pay should be considered while the case is being investigated. This allows tempers to cool and hasty action to be avoided. Any suspension must be with pay unless the contract of employment allows suspension without pay, and any period of suspension should be as short as possible…..Do not use suspension as a sanction before the disciplinary meeting and decision and treat employees fairly and consistently.
“Seek an external review if a disciplinary case is not concluded within  months. An external HR director might be asked to look at the case, for example.”
“Recognise that events can move on and that formal disciplinary action, while initially appearing appropriate, may cease to be right. An alternative way of bringing the case to resolution must then be actively sought and found.”
Finally the Toolkit draws attention to the responsibility to support physicians who have been made the subject of concerns. Reference is made to a NHS clinical practice guideline on psychological therapy and counseling in demonstrating benefit in terms of returning employees to work. Emphasis is placed on the difficulties involved in returning to the workforce after an absence, including a guidance on achieving this. The Royal College of Obstetrics and Gynaecology has also published a policy on this.
NCAA has commenced a number of important research projects into why things go wrong in health care and how to prevent and manage them. A new report released in November 2004, is ‘Understanding Performance Difficulties in Doctors’, by Professor Jenny Firth-Cozens, which will be expanded into a book during 2005. The answers are not easy but complex, and are predicated on the fact that highly committed, conscientious, well intentioned and dedicated individuals run into problems for a variety of reasons, many of which are not of their own doing.
“Performance is affected by a complex interplay of personal and situational factors including organisational culture, physical environment, teamwork and leadership. Workload, sleep loss and shift patterns can all have a deleterious effect on clinical performance. Workload, for example, affects physical and mental ability in the form of decision making, attention span, fine motor control and level of motivation. Sleep loss increases the risk of human error and shift work can cause biological disruption which in turn may lead to impaired health and psychological well-being including ‘risky’ coping behaviours such as alcohol or drug misuse.”
Taking the general principle that these are workplace issues, and therefore amenable to an occupational health perspective, these can best solved by into looking at the interaction between the individual and their environment.
They suggest 14 questions managers should ask to solve the problems of ‘Why did this happen?’ and ‘What interventions are appropriate?’, both at an individual and organisational level. These include evaluating physical health and disability, mental health, stress, life events, cognitive impairment, medications, substance use, personal characteristics, attitudes and behaviour, issues related to education and training, organisational culture, workload, team function, and leadership.
“We have provided an analysis of why the performance of a minority of doctors – intelligent individuals who have been sufficiently talented and motivated to complete demanding training and qualify as doctors – causes concern.”
The factors fall into three broad categories:
• Physical health
• Psychological health
• Cognitive function
• Personality, attitudes and behaviour
• Clinical knowledge and skills.
Factors associated with the work environment
• Climate and culture
• Workload, sleep and shift-work.
Education, training and continuing professional development
• Selection of future doctors
• Undergraduate education
• Postgraduate training
• Continuing professional development (CPD).”
In examining the role of the organisation in which the individual functions, the authors recognise that medicine is an environment associated with high levels of stress and burnout;
There is no doubt that the organisation plays a large part in the mental health of its staff.
Organisational causes of stress include all those which research shows lead to stress in workers in general: poor support from supervisors and managers; poor teamwork; lack of control over how the tasks are performed; overload and a lack of resources. Sleep loss has a significant effect in lowering mood. In addition, within medicine a major and increasing stressor includes a fear of making mistakes and of litigation and complaints. An organisational culture which is open and fair and where trust is high is likely to reduce this stressor.
Organisations may help to prevent high stress levels and promote mental health by good management practices and supportive cultures. The growing use of mentoring and coaching may also prove to have a preventive role.”…
“It is important that people and the way tasks are performed are not seen as problematic merely because they differ from those who are judging them. The Myers Briggs Type Inventory (MBTI) is a useful way of understanding normal differences which, used well, are necessary strengths in the workplace. When conflicts arise it is worth considering whether they are due more to different approaches and preferences of each party rather than the underlying personality of one. If overplayed, strengths can become problematic, but not irremediable. For example, confidence can become arrogance, diligence can become perfection and charm can become manipulation.”…
“The evidence concerning culture, climate and organisational performance of hospitals is still largely indirect but is growing in strength. For example, there is some evidence concerning lower mortality in US hospitals which nurses perceive to be good places to work. ….
Also of growing importance, easier to measure, and likely to be affected by culture and leadership, are human resource management (HRM) practices. Studies outside health care have shown that better HRM practices are associated with higher levels of organisational productivity and effectiveness. Within health care there is a relationship between some HRM practices (such as the extensiveness and sophistication of appraisal, training and teamwork) and patient mortality.” …
“A Culture of Safety
A safety culture is not separate from the general organisational culture but at its core. It involves fairness and openness, rather than blame, in dealing with adverse
incidents. The development of a safety culture requires trust and good leadership. Reliable organisations have the following cultural values:
Co-workers who are helpful and supportive of one another
Friendly, open and sensitive personal relations
Strong feelings of credibility and trust
“Can culture be changed?
Culture and climate can be changed when new leaders introduce different values and ways of working. The dramatic differences that result from external forces such as mergers show that cultural change is possible and can be remarkably fast. There is also evidence that culture can be extremely resistant to change during mergers unless work is specifically undertaken to improve it.”
Despite the fact that most people who work in health care environments do so within various teams, to date there has been little data on how well teams function. However the data from the UK 2003 National Staff Survey of health care workers show that much less than half of them work in effective teams – those linked with productivity gains and service benefits.
What are the key elements of an effective team?
“●Its task is defined and its objectives clear
●It has reasonably clear boundaries and is not too large (ideally fewer than 10 people)
●Its members know who leads it and the leadership is good
●There is participation in decision-making by all members, good communication, and frequent interaction between them
●It meets regularly to review its objectives, methods and effectiveness
●Its meetings are well conducted
●Its members trust each other and feel safe to speak their minds
●There is a shared commitment to excellence of patient care.”
Group processes are well known to be powerful influences on individual performance. Effective teams function at a much higher level of quality care than any of the individuals within the team, and individuals in quality teams are significantly less stressed, which in itself is related to better patient care.
Amongst those characteristics of teams that have been shown to impact most on individual performance are;
“●Diversity is important in teams, reflecting the complexity of service delivery and the heterogeneity of patients, and leading to better decision-making. However, diversity sometimes causes difficulties in the early days of team development
●Scape-goating – heaping onto one group member the problems of the team as a whole - is a well-established tendency of groups. Leaders and members need to be alert to this possibility or the real causes of poor performance may be missed
●The longer teams are together the better they perform, but this can be difficult for more transient members such as doctors in training
●Good leadership is essential to ensure that a team, and its individual members, perform well.”
Our understanding of how leadership affects team function has also increased considerably.
“Leadership qualities affect the work of both the leaders themselves, and those whom they lead. When performance problems arise it is important to consider not only individuals’ characteristics and the context which may contribute to the problems, but also those of their superiors. There is growing evidence of direct and indirect links between the qualities of leaders and the quality of patient care. This occurs because leaders affect the performance of individuals and teams” 
Useful resources for clinical leadership have been gathered together in an NHS website. Much of what we have to learn about optimizing the working environment in health care is simply a matter of testing and applying lessons learnt in the private sector.
In summary, the key elements are recognizing the roles of teams, organizational culture and leadership;
“The relative contributions of the individual practitioner and the environment in which he/she works should be taken into consideration when a doctor appears to be performing poorly.
Fewer patients die when they are looked after by well managed teams, which are also more cost-effective. The evidence points to the importance for patient outcomes of a culture that promotes patient safety. Effective leadership increases the performance of teams and reduces stress in team members. Teamwork, organisational culture and leadership can be improved by interventions to train and support leaders, and through team development and feedback.”
Auditor General’s and Committee of Public Accounts Reports
Two subsequent reports investigated the situation from the perspective of public accountability.
The Comptroller and Auditor General issued his report in November 2003 which was followed by a report from the Committee of Public Accounts of the House of Commons in November 2004. 
The Auditor General’s office looked at exclusions from the work force between April 2001 and July 2002, and estimated the cost at ₤29 million for the 1,000 staff (0.14% of the workforce), not counting employment costs at full pay (₤11m), or settlement and retraining, in a total health budget of ₤55 billion While the terms of reference dealt primarily with the public costs, the report also addressed the human costs;
“there is also a loss of clinical skills as a result of the enforced absence, with staff being paid to stay at home and not normally allowed to treat patients. For the clinician, exclusion can result in reduced self-esteem and depression, and in some cases, the clinician may feel suicidal. The clinician's family can also be adversely affected. A number of clinicians never work again, even if they are exonerated by enquiries. Clinical staff may well have undertaken expensive training and, with shortages of many staff across the NHS, unnecessary exclusions or cases where clinicians consider they have been driven out of the health service are of concern, both in terms of personal fairness and equity, and waste of scarce resources.”
These reports provide some perspective on progress and highlight ongoing problems. They also included a number of case studies. In looking at alternative actions to exclusion they noted;
“It may be possible to restrict some clinical activities, avoiding certain procedures or types of patient, whilst enabling an investigation to be conducted. Clinical staff may be able to undertake clinical audit or research activities, or attend training courses… A number of exclusions occur as a result of a breakdown in team working or personality clashes where there appears to be no risk to patients. Where there have been patient safety incidents, trusts have sometimes excluded clinicians despite evidence of systemic failures rather than individual shortcomings… [they] need to support excluded clinical staff to enable them to progress their continuing professional development. ”
Amongst recommendations were involvement of the Royal Colleges in assessments, ensuring;
“systems are in place to provide support to staff so that they are successfully integrated back into clinical work…[and]…a support system for excluded staff which includes regular contact with a mentor to ensure their psychological well being is monitored and they have access to continuing professional development so their skill base is maintained.”
In their sample some 40% of doctors and dentists returned to work. There was concern that management often acted in a ‘knee-jerk’ fashion without adequate inquiry. In looking at the degree to which employers had followed government policies, they noted that another tool that employers had utilized were the services of another statutory authority, the Advisory, Conciliation and Arbitration Service (ACAS). Patient safety was not an issue in the majority of cases. In their interviews the survey team found employers frequently failed to adhere to best management practices. Nor did they find much evidence of management being held accountable, despite evidence of poor working relationships between management and medical staff.
Many of these recommendations have now been incorporated into NHS policy. However a year later the Committee of Public Accounts remained critical of the progress that was being made. It noted that under a system of government funded medicine, the Department of Health is effectively a monopoly employer, therefore ‘the burden of proof required to terminate a clinician’s contract on grounds of professional competence is high.’ In some workplaces the Committee were disturbed to note that there was effectively a ‘culture of fear’ not only among clinicians who felt victimized, but among those who had witnessed what had happened to colleagues who spoke out.
Amongst submissions to the committee was that of the Medical Protection Society, which defends doctors and which noted the devastating consequences of the use of exclusions.
Case Study 1: Wendy Savage
Mrs Wendy Savage was an obstetrician at the University of London, who had a somewhat controversial style. In particular she differed from many of her colleagues in championing minimum intervention in childbirth, and promoting vaginal delivery over caesarean section wherever possible. She was a strong patient advocate believing in patients making informed choices.
She had been appointed to her post in 1977. In 1983 a new, younger division head was appointed. During 1984 there were some disagreements between the two, and a colleague complained about the care of a patient. In 1985 her division head and the District Health Authority suspended her, based on what they considered to be incompetence, poor clinical judgement and exposure of patients to unnecessary risks and poor communication with colleagues such as to interfere with safe care. A court challenge was unsuccessful. Five cases were selected by the Health Authority as being representative of her practice, for criticism, however it acceded to a request for an inquiry to be in public.
Both sides retained expert witnesses who reviewed the cases with very different results. An external panel consisting of two obstetricians and a lawyer, was convened and conducted the inquiry in 1986. Her colleagues criticised her as defensive, and unwilling to accept fault, and to recognise concerns in others for patient safety. Because of the public nature of the inquiry, the subject of her practice, the nature of the controversy and the type of patients that she saw, the whole affair generated intense public interest with demonstrations, media coverage and questions in Parliament.
Later that year, the inquiry report was released. Essentially the panel concluded that there was no evidence of a systematic ‘aberration of clinical judgement’, although some decisions were described as being ‘close to the bounds of acceptable practice’. Nor did they find evidence of unacceptable exposure to risk. They found no evidence that the cases presented represented a pattern of unacceptable risk, and found evidence that when at fault, she willingly applied lessons learned to future practice. They found that Mrs Savage demonstrated an equal concern for patient safety as did her colleagues. The panel also rejected the allegation that she should be held personally responsible for all adverse events experienced by her patients, even when under the care of others. Nor did they find evidence that in her interactions with colleagues she endangered the delivery of safe care.
The Health Authority accepted to report and decided to reinstate her after a 15 month suspension. The Authority was, however left with the problem of trying to reintegrate a specialist into practice, following repudiation by her colleagues and superiors. They therefore appointed an advisory panel to “make recommendations on how professional working arrangements can properly be established within the department of obstetrics” the panel acknowledged that there “differences of opinion…about the emphasis given to various elements of acknowledged good practice” and that there had been a “breakdown in relationships”. The roots of this were considered to be that the division “lacked effective leadership and cohesion and a mechanism for resolving conflicts between colleagues”.
Noting that good practice requires “complete trust between the participants and at least a broad consensus on operational policies”, the panel concluded that the situation has arisen because “this broad consensus was missing and from a breakdown of trust between Mrs Savage and certain members of the team, particularly where her management of a complicated case has been unusual or unfamiliar”. It acknowledged that while, ideally, working arrangements should be resolved between professionals themselves “the situation in the obstetrics and gynaecology division has reached a point where the division itself cannot resolve its problems.”
The decision of the panel was to leave differences of opinion that might arise in future to an internal panel of specialists and the Dean, to resolve. It stated that consultants must adhere to joint policies and that in the situation where management might be considered unusual or unfamiliar, the consultant concerned would take personal and direct responsibility for the management. It suggested merging the division with another division “to give a wider perspective to its deliberations”. They also suggested that any “unresolved differences on clinical philosophy may be referred to the Royal College of Obstetricians and Gynaecologists” (which was represented on the panel). Finally it drew the attention of those involved to the professional ethic that “As required by the General Medical Council in its guidance to the profession, medical practitioners involved in these arrangements must refrain from depreciating the professional skills and services of others.”
The panel was realistic enough to note that “it may well take a little time to establish professional working relationships and the teamwork required. Success will require the sincere determination of all parties to work in harmony, with tolerance and respect for each other’s viewpoints. We trust that in the interests of the women of Tower Hamlets they will do so.”
It was decided that in was in the public interest to publish the report and the Health Authority’s response. The Authority responded that it “requires the consultants in obstetrics and gynaecology and their colleagues to make working arrangements as recommended…within one week. The Authority appreciates the feelings of the consultants in this matter but asks them to find it in their hearts to make these arrangements in order to serve the local community”.
Mrs Savage returned to work, nobody left, and the affair became a national legend, particularly with regard to women’s right to choose. There continued to be considerable public comment on the flawed process which led a public body to expend large amounts of resources on prosecuting what were essentially differences in opinion and personality.
As Savage herself put it “if we ignore the history of this affair we will be condemned to repeat it. Unless the fundamental issues are dealt with doctors who are guilty of nothing more than having a different approach from that of some of their colleagues will continue to suffer as I have done”.
Mrs Savage has now retired and works as a screener for complaints to the GMC.
Case Study 2: Bristol Royal Infirmary
A new anaesthetist in the paediatric cardiac surgery unit in 1988 noted procedures that seemed unfamiliar to him and a higher operative mortality than he was used to seeing. Two years later he started to voice his concerns. The hospital admitted there were problems in 1995. In 1996 parents wrote to authorities asking for a review. Preliminary investigations in 1997 suggested that the mortality rate was exceptionally high. The CEO and the two surgeons involved were referred to disciplinary procedures. An independent inquiry was announced. In 1998 the three people charged with misconduct were found guilty and disciplined.
The Kennedy inquiry heard evidence between 1998 and 2001, and released its report in 2000. Many recommendations were planned and implemented, and a formal response, ‘Learning from Bristol’ was published in 2002. The implications of the inquiry continue to reverberate.
While many were expecting a “stinging attack” what emerged was a remarkable insight into where things go wrong in health care systems that has formed the basis for all subsequent inquiries. Unfortunately the immediate impact of the Bristol ‘scandal’ had been a sharp rise in disciplinary actions against doctors. The Kennedy report helped to rebalance the perspective, marking a transition from a ‘culture of blame’ to a culture of understanding and learning.
The report’s summary addresses the fundamental issues;
The story of the paediatric cardiac surgical service in Bristol is not an account of bad people. Nor is it an account of people who did not care, nor of people who wilfully harmed patients.
It is an account of people who cared greatly about human suffering, and were dedicated and well-motivated. Sadly, some lacked insight and their behaviour was flawed. Many failed to communicate with each other, and to work together effectively for the interests of their patients. There was a lack of leadership, and of teamwork.
It is an account of healthcare professionals working in Bristol who were victims of a combination of circumstances which owed as much to general failings in the NHS at the time than any individual failing. Despite their manifest good intentions and long hours of dedicated work, there were failures on occasion in the care provided to very sick children. ….
It is an account of a time when there was no agreed means of assessing the quality of care. There were no standards for evaluating performance. There was confusion throughout the NHS as to who was responsible for monitoring the quality of care.
It is an account of a hospital where there was a `club culture'; an imbalance of power, with too much control in the hands of a few individuals. …
And it is an account of a system of hospital care which was poorly organised. It was beset with uncertainty as to how to get things done, such that when concerns were raised, it took years for them to be taken seriously. ….
The circumstances of Bristol, and the NHS, at the time, led to the system for providing paediatric cardiac surgery (PCS) being flawed. All of these flaws, taken together, led to around one-third of all the children who underwent open-heart surgery receiving less than adequate care. “
This represented a fundamental shift from inquiries that allocated blame to those that sought an understanding, in order to reduce repetitive episodes.
“We adopt a `systems' approach to analysis, by which poor performance and errors are seen as the product of systems which are not working well, as much as the result of any particular individual's conduct.”
Amongst the findings the report addressed the crucial functions of teamwork and leadership;
“We reach one conclusion which owes nothing to hindsight. There was poor teamwork and this had implications for performance and outcome. The crucial importance of effective teamwork in this complex area of surgery was very widely recognised…. All the professionals involved in the PCS service were responsible for this shortcoming. But, in particular, this poor teamwork demonstrates a clear lack of effective clinical leadership. Those in positions of clinical leadership must bear the responsibility for this failure and the undoubtedly adverse effect it had on the adequacy of the PCS service.”…
“What was unusual about Bristol was that the systems and culture in place were such as to make open discussion and review more difficult. Staff were not encouraged to share their problems or to speak openly. Those who tried to raise concerns found it hard to have their voice heard…. there was power but no leadership. The environment was one in which problems were neither adequately identified nor addressed.”…
“We cannot say that the external system for assuring and monitoring the quality of care was inadequate. There was, in truth, no such system.”
The guiding principles on which recommendations were made included;
“· Patients must be at the centre of the NHS, and thus the patient's perspective must be included in the policies, planning and delivery of services at every level.
· The dedication and commitment of NHS staff is and must remain at the core of the service.
· The quality of healthcare must include all aspects of care: clinical and non-clinical.
· Patients' safety must be the foundation of quality.
· Systems of care, and facilities, as well as individuals, affect the quality of healthcare.
· Learning from error, rather than seeking someone to blame, must be the priority in order to improve safety and quality.
· Openness and transparency are as crucial to the development of trust between healthcare professional and patient, as they are to the trust between the NHS and the public.”
Amongst the many recommendations were;
“Safety: …For the future, the NHS must root out unsafe practices. It must remove barriers to safe care. In particular, it must promote openness and the preparedness to acknowledge errors and to learn lessons. Healthcare professionals should have a duty of candour to patients. Clinical negligence litigation, as a barrier to openness, should be abolished. Safe care should be promoted….”.
“The culture of the NHS
The culture of the future must be a culture of safety and of quality; a culture of openness and of accountability; a culture of public service; a culture in which collaborative teamwork is prized; and a culture of flexibility in which innovation can flourish in response to patients' needs.”
“Respect and honesty
Patients in their journey through the healthcare system are entitled to be treated with respect and honesty and to be involved, wherever possible, in decisions about their care
The quality of healthcare would be enhanced by a greater degree of respect and honesty in the relationship between healthcare professional and patient. Good communication is essential, but as the Royal College of Surgeons of England told us: `... it is the area of greatest compromise…and the source of most complaints'.
Partnership between patient and healthcare professional is the way forward. The exchange and provision of information is at the core of an open and honest relationship between healthcare professionals and patients. There are four fundamental principles which should in future underpin any policy aimed at meeting patients' needs for information. First, trust can only be sustained by openness. Secondly, openness means that information be given freely, honestly and regularly. Thirdly, it is of fundamental importance to be honest about the twin concerns of risk and uncertainty. Lastly, informing patients…must be regarded as a process and not a one-off event.”…
“The safety of care
The components of safe care are much more than the actions or competence of healthcare professionals: they include the physical environment, equipment, working arrangements, teamwork and good communication.
The NHS is still failing to learn from the things that go wrong and has no system to put this right. This must change.
A culture of safety in which safety is everyone's concern must be created. Safety requires constant vigilance. Given that errors happen, they must be analysed with a view to anticipate and avoid them.
A culture of safety crucially requires the creation of an open, free, non-punitive environment in which healthcare professionals can feel safe to report adverse events and near misses (sentinel events). …
The culture of blame is a major barrier to the openness required if sentinel events are to be reported, lessons learned and safety improved. The system of clinical negligence is part of this culture of blame….It should be replaced by effective systems for identifying, analysing, learning from and preventing errors and other sentinel events.”
“Clinical standards for the care of patients
For the future, standards for clinical care must be set [and] must be patient-centred. They must not be the product of individual professional groups talking to themselves.”
Finally, on public input and empowerment;
“Public involvement through empowerment
The public are entitled to expect that means exist for them to become involved in the planning, organisation and delivery of healthcare
A patient-centred service is one that is designed and planned to address the needs of the particular sectors of the public it exists to serve. Strategic planning at national level, and decisions at local level must involve the public.
In its everyday working the NHS must take account of and respond to the interests and needs of the public.
The public must be involved in those processes designed to secure the competence of healthcare professionals
The principles which should inform future policy about involving the public and patients in the NHS include:
Patients and the public are entitled to be involved wherever decisions are taken about care in the NHS.
The involvement of patients and the public must be embedded in the structures of the NHS and permeate all aspects of healthcare.
The public and patients should have access to relevant information.
Healthcare professionals must be partners in the process of involving the public.
There must be honesty about the scope of the public's involvement, since some decisions cannot be made by the public.
There must be transparency and openness in the procedures for involving the public and patients.
The mechanisms for involvement should be evaluated for their effectiveness.
The public and patients should have access to training and funding to allow them fully to participate.
The public should be represented by a wide range of individuals and groups and not by particular `patients' groups'.
The priority for involving the public should be that their interests are embedded into all organisations and institutions concerned with quality of performance in the NHS: in other words, the public should be `on the inside', rather than represented by some organisation `on the outside'.”
The Kennedy inquiry made a conscientious effort to make their report definitive, not just for the management, staff and public in Bristol, but the entire health care system, a generalisability concept that came to be known as ‘An Organisation with a Memory’. They strove to understand the actions of individuals within their environment, and what were the factors that drove them to make certain decisions and take certain actions. Actions which at worst they were to describe as “individuals who, in our view, could and should on occasions have behaved differently”.
The issues, as always were complex, and multifaceted.
“There are no right answers; just, perhaps, less wrong answers.…the recommendations are interlocked and interrelated. They are parts of a jigsaw: each needs t other to complete the picture”
However, lessons learned from Bristol underpin almost every reform in the NHS since then.
Australia has had its share of problems in health care, including the King Edward Memorial Hospital inquiries in Perth, resulting in the Douglas Report and subsequent disciplinary hearings and Government responses. This found widespread system and cultural failures in the delivery of services despite repeated complaints and investigations.
In response to this and other developments both within Australia and globally, a number of national initiatives were undertaken.
In parallel with similar initiatives in other countries a Patient Safety Foundation was established and the Australian Council for Safety and Quality in Health Care developed standards for open disclosure of incidents in 2003. This follows the same concept as in the UK of providing a supportive environment as opposed to a punitive one (while preserving accountability).
Other recent initiatives in this area include gathering evidence during 2004 for a ‘Review of Future Governance Arrangements for Safety and Quality in Health Care’.. A draft National Patient Safety Education Framework (2004) addresses many additional areas such as the role of teamwork, leadership, conflict resolution, organisational theory, factors that influence performance, fitness to practice and ethics. However no formal national framework for managing concerns exists yet.
This has become a more pressing matter since the release of the report of the Walker inquiry report in 2004.
Case Study: Walker Inquiry
Four nurses acted as ‘whistleblowers’ in a group of two hospitals forming an outer Sydney health service area in New South Wales (Camden and Campbelltown Hospitals) in November 2002. Their complaints of unsafe and inadequate care were then investigated by the Health Care Complaints Commission (HCCC) which reported in December 2003 ‘substantiating’ the allegations.,
Following considerable concerns about the HCCC process and report, a special commission was convened in the same month and reported in June 2004. This commission found considerable fault with the original process. In particular it noted procedural unfairness and ‘deplorable delay’. Subsequently the HCCC commissioner was dismissed. A parliamentary committee also sharply criticised ‘unacceptable delays in investigations’. New performance standards have been put in place.
Under Australian Law, there is a duty of procedural fairness even where legal rights are not affected but reputation may be. The HCCC undeniably violated that. In the final report of the inquiry, the commission was critical of the relationship between disciplinary processes and quality of care.
“Insensitive or overly vindictive disciplinary action can be counter-productive in relation to the overall improvement of health care standards.”
Our thinking about improving quality of care, patient safety, medical error, professional development and regulation, physician wellness and the healthy workplace are converging, but lack a comprehensive framework in most jurisdictions. The evolution has incorporated research into organisational theory, management, team function, human resources, occupational health and psychology, and conflict management.
Appropriately managed, health care settings can develop continuous quality improvement minimise concerns arising from the workplace, and when they do occur, deal with them constructively in a way that minimises disruption of the delivery of care, conserves resources and prevents repetitive problems.
Traditional models for dealing with concerns were reactive, adversarial and punitive, created a false sense of reassurance in terms of the maintenance of quality care, and of protecting the public and were resource intensive. Consequently their impact was more often counterproductive than not.
Often the only recourse health care systems and regulatory bodies had for dealing with concerns were traditional disciplinary structures. Many regulatory authorities have moved towards alternative dispute resolution methods and away from confrontation, in their complaints mechanism.
With appropriate proactive policies, there should be little need for disciplinary procedures which are best reserved for gross misconduct and should apply equitably across the workforce.
Situations in which exclusion from the workforce (suspension) are felt to be the only feasible alternative, should be an extraordinary occurrence, and should be for a minimal period. Clinicians need to be viewed as resources and investments.
Factors involving performance are complex and most frequently reflect an interaction between those that are intrinsic to the individual, and their interaction with external factors.
Assessments and investigations are best managed by bodies external to the organisation to minimise bias and maximise expertise.
Finally the unique situation of university teaching hospitals must be recognised, not only because there is an additional chain of command, but because of the need to consider and protect research and teaching commitments.
Dr Michael Goodyear
Department of Medicine, Dalhousie University
Appendix I: Selected Quotations
Good education and training relevant to the needs of the modern health service, reinforced by continuing learning and professional development throughout a career are the cornerstone to preventing poor individual performance… Clinical audit is an effective tool for reflecting on and improving care. Significant event reporting can help to celebrate good care whilst also identifying opportunities for improvement.
British Medical Association
We believe it is extremely important that proposals recognise the organisational aspects of dealing with poor performance , which may not simply be a result of individual practice but flow from problems associated with organisational culture , managerial or leadership issues.
The early detection of… lowered standards is important, but this must be matched by immediate and focused help with retraining, counselling and mentorship… There is, I believe, general support for local arrangements to assist doctors in difficulties which are external …but at the level of a Region …with close links to Regional Advisors and Programme Directors and with established procedures for remedial training….Examination of performance must be carried out within the doctor's working environment.
Royal College of Psychiatrists
The importance of early detection together with the emphasis on rehabilitation and educational
solutions rather than disciplinary ones is also welcomed.
Joint Consultants’ Committee
It is crucial that…the stigma of having one's clinical performance questioned is removed…. BAMM has discussed this issue at some length. The view is that these …centres could conceivably provide a service that is wider than dealing with poorly performing doctors… including those returning to medicine after a career break, those keen to enter a different stream of a specialty….
British Association of Medical Managers
Criminals who commit serious offences are treated better than suspended doctors..lives and careers are wrecked
Baroness Knight of Collingtree
It [suspension] introduces an immediate stigma, increases the degree of confrontation, and makes informal and agreed solutions much more difficult.
Dr Liam Donaldson, Regional Medical Officer, Northern and Yorkshire Health Authority
Many of these disciplinary actions are inspired by professional jealousies and personal grudges, and the whole business then becomes a profoundly wasteful business.
Dr Peter Tomlin, Chair, Society of Clinical Psychiatrists Study Group
Some colleagues regard a different style of clinical practice as incompetence..motives included …professional jealousy, and power struggles…it is easy to dress up allegations so that an administrator suspends the doctor first and investigates afterwards
Dr Peter Tomlin
Insensitive or overly vindictive disciplinary action can be counter-productive in relation to the overall improvement of health care standards.
Walker Inquiry: Special Commission of Inquiry into Campbelltown and Camden Hospitals,
Government of New South Wales, Australia, June 30th 2004.
Draconian measures have a tendency to lower the safety culture.
Professor Firth-Cozens 2004
If disciplinary action is taken – action that may, in fact, be counter-productive to creating a positive change in physician behaviour.
College of Physicians and Surgeons of Alberta
The loss of my job was like a bereavement. Powerful, confusing and shifting emotions swept over me - disbelief (can this really be happening?), sadness, guilt, self-doubt and anger.
Professor Wendy Savage
If we ignore the history of this affair we will be condemned to repeat it. Unless the fundamental issues are dealt with doctors who are guilty of nothing more than having a different approach from that of some of their colleagues will continue to suffer as I have done.
Professor Wendy Savage
As required by the General Medical Council in its guidance to the profession, medical practitioners involved in these arrangements must refrain from depreciating the professional skills and services of others.
Munro Report , October 25 1986
Poor performance and errors are seen as the product of systems which are not working well, as much as the result of any particular individual's conduct.
Kennedy Report, July 2001
Learning…, rather than seeking someone to blame, must be the priority in order to improve safety and quality
Openness and transparency are as crucial to the development of trust between healthcare professional and patient, as they are to the trust between the NHS and the public.
Partnership between patient and healthcare professional is the way forward. The exchange and provision of information is at the core of an open and honest relationship between healthcare professionals and patients.
There are four fundamental principles which should in future underpin any policy aimed at meeting patients' needs for information. First, trust can only be sustained by openness. Secondly, openness means that information be given freely, honestly and regularly. Thirdly, it is of fundamental importance to be honest about the twin concerns of risk and uncertainty. Lastly, informing patients…must be regarded as a process.
It is an account of a hospital where there was a `club culture'; an imbalance of power, with too much control in the hands of a few individuals.
Those who tried to raise concerns found it hard to have their voice heard…. there was power but no leadership. The environment was one in which problems were neither adequately identified nor addressed.
People with skills are expensive to replace. It makes sense to try to rebuild a career rather than scrapping probably still useful experience, skills and knowledge.
National Clinical Assessment Authority
Rebuilding is right, humane and also required by the Code of Conduct for NHS managers which puts a duty on managers to help staff ‘maintain and improve their knowledge and skills and achieve their potential’.
National Clinical Assessment Authority
Some ‘performance problems’ have their origins simply in a clash of values between manager and clinician.
National Clinical Assessment Authority
Teams exist for purposes, one of which is quality assurance and performance management. The [organisation] needs everyone to take ownership of performance problems and contribute to solving them.
National Clinical Assessment Authority
It must be clear that an organisation’s values statement is not just a PR device but a practical guide to decision-making.
National Clinical Assessment Authority
Differences in work style are normally expected by colleagues and tolerated. But sometimes a different style will attract criticism and come to be seen as a sign of poor performance. If the person first categorising performance as poor is influential, then others may take the same view.
National Clinical Assessment Authority
It is important that people and the way tasks are performed are not seen as problematic merely because they differ from those who are judging them…normal differences which, used well, are necessary strengths in the workplace. When conflicts arise it is worth considering whether they are due more to different approaches and preferences of each party rather than the underlying personality of one.
National Clinical Assessment Authority
Exclusion of clinical staff from the workplace is a temporary expedient…a precautionary measure and not a disciplinary sanction. Exclusion from work ("suspension") should be reserved for only the most exceptional circumstances.
Department of Health (England), 2004
A number of exclusions occur as a result of a breakdown in team working or personality clashes where there appears to be no risk to patients. Where there have been patient safety incidents, trusts have sometimes excluded clinicians despite evidence of systemic failures rather than individual shortcomings… [they] need to support excluded clinical staff to enable them to progress their continuing professional development.
Auditor-General’s Office, 2003
Systems are in place to provide support to staff so that they are successfully integrated back into clinical work…[and]…a support system for excluded staff which includes regular contact with a mentor to ensure their psychological well being is monitored and they have access to continuing professional development so their skill base is maintained.
Auditor-General’s Office, 2003
The NHS is in effect a monopoly employer, so the burden of proof required to terminate a clinician’s contract on grounds of professional competence is high.
Committee of Public Accounts, House of Commons: The management of suspensions of clinical staff in NHS hospitals and ambulance trusts in England. November 2004
Cultures of blame, authoritarianism, narrow mindedness and reckless disregard for staff are not to be tolerated… the model which emerges here is one of down-to-earth decency, humanity, humility, sensitivity and respect for others, but this is no soft option.
Beverley Alimo-Metcalfe, Professorship of Leadership Studies, Leeds University. 2000
Appendix II: Supplementary papers
Goodyear M. Conflict Management in Health Care Teams: A new paradigm - Safer care: Saving costs August 2006 http://myweb.dal.ca/mgoodyea/files/conlict.doc
Goodyear M. Conflict Management in Health Care Teams: A new paradigm - Safer care: Saving costs August 2006 http://myweb.dal.ca/mgoodyea/files/conflict.doc
 Johnston RV, Boiteau P, Charlebois K, Long S, U D. Responding to tragic error: lessons from Foothills Medical Centre. CMAJ. 2004 May 25;170(11):1659-60.
 Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J, Etchells E, Ghali WA, Hebert P, Majumdar SR, O'Beirne M, Palacios-Derflingher L, Reid RJ, Sheps S, Tamblyn R. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ. 2004 May 25;170(11):1678-86.
 Supporting Doctors, Protecting Patients 1999 p39
 Building a Safer System. National Steering Committee on Patient Safety. Ottawa 2002. Executive Summary viii Recommendation 5. http://rcpsc.medical.org/publications/building_a_safer_system_e.pdf
 Ibid. viii Recommendation 8.
 Ibid 7
 Ibid 11
 Ibid 12
 Ibid 14
 Ibid 15
 Ibid 16
 Robson R. Debating the patient's "right to know". CMAJ. 1999 Oct 19;161(8):944, 946.
 Sibbald B. Winnipeg inquest recommendations watered down, parents say. CMAJ. 2001 Oct 30;165(9):1242
 Error and blame: the Winnipeg inquest. CMAJ. 2001 Nov 27;165(11):1461, 1463.
 FMLAC. Subsequently renamed FMRAC (Federation of Medical Regulatory Authorities). http://www.fmrac.ca/index.cfm
 Compendium of proceedings of the Aylmer workshops. Federation of Medical Regulatory Authorities of Canada. Ottawa 2000
 College of Physicians and Surgeons of Alberta. Complaint Process. http://www.cpsa.ab.ca/complaints/attachments/boundary_complaints.pdf
 College of Physicians and Surgeons of Ontario. Peer Assessment. http://www.cpso.on.ca/Info_Public/factpeer.htm
 Thompson J, Baird P, Downie J. Report of the Committee of Inquiry on the Case involving Dr. Nancy Olivieri, The Hospital for Sick Children, The University of Toronto and Apotex inc. Canadian Association of University Teachers, Ottawa 2001. http://www.caut.ca/en/issues/academicfreedom/OlivieriInquiryReport.pdf
 Supplement to the Report, January 2002 http://www.caut.ca/en/issues/academicfreedom/SupplementtoInqReport.pdf
 Complaints Committee Decision and Reasons, College of Physicians of Ontario November 2001 http://www.caut.ca/en/issues/academicfreedom/Olivieri_CPSO.pdf
 CPSO Discipline Committee Decisions http://www.cpso.on.ca/publications/discsum/2004/discmay04.htm#Koren
 Report of the Committee op cit recommendations 17, 18 p43-4
 Editorial: Questions of interest. CMAJ, 2002; 166 (4): 413
 Viens AM, Savulescu J. Introduction to The Olivieri symposium. J Med Ethics 2004;30:1-7
 The Globe and Mail, cited in Viens and Savelescu op cit.
 CAUT Policy Statement on Academic Appointments Held Jointly in a University and a Related Institution. http://www.caut.ca/en/policies/jointappointments.asp
 Defending Medicine: Clinical faculty and academic freedom CAUT 2004.
 Donaldson L. Commentary: The Doctor’s Dilemma: A response. International Journal of Epidemiology 2003;32:915-916
 Griffiths R. Report of a review of the research framework in the North Staffordshire Hospitals NHS Trust. NHS Executive West Midlands Regional Office 2000 http://www.dh.gov.uk/assetRoot/04/01/45/42/04014542.pdf
 Ritchie J. The Report of the Inquiry into Quality and Practice Within the National Health Service Arising from the Actions of Rodney Ledward. London: NHS Executive South East Regional Office, 2000. http://www.dh.gov.uk/assetRoot/04/09/33/42/04093342.pdf
 The Royal Liverpool Children’s Inquiry – Report and Summary and Recommendations (The Redfern Report) HMSO 30 January 2001 (HC 12-1)
 Kennedy I. Learning from Bristol: the Report of the Public Inquiry into Children’s Heart Surgery at the Bristol Royal Infirmary 1984–1995. London: The Stationery Office, 2001 (Cm 5207).
 40th Report from the Committee of Public Accounts 1994-95 'Suspension of Dr O'Connell' HC 322
 Donaldson L. Doctors with problems in an NHS workforce. BMJ 308: 1277-1282, 1994
 See Appendix: Selected Quotations
 General Medical Council. Proposals for new performance procedures: a consultation paper. London, 1992
 BMJ 317: 811-2, 1998
 A consultation paper on preventing, recognising and dealing with poor clinical performance of doctors in the NHS in England http://www.dh.gov.uk/assetRoot/04/04/28/02/04042802.pdf
 Suspensions - a new perspective: Report of the short-life working group on suspension of medical and dental staff. Scottish Office, Department of Health 1999. (Circular PCS(DD)1999/7, 6 April 1999.
 Supporting doctors Foreword p3
 Ibid 7
 Ibid 37
 A Savage inquiry
 See Auditor General’s and Committee of Public Accounts Reports
 Supporting doctors p8
 Ibid 9
 Ibid 40
 The New NHS Modern, Dependable. Department of Health 1997. http://www.archive.official-documents.co.uk/document/doh/newnhs/newnhs.htm
 Supporting Doctors Ibid 11
 Ibid 19
 Ibid 34
 Improving the Health of the NHS Workforce- Report of the Partnership on the Health of the NHS Workforce Nuffield Trust, 1998
 Dr Eva Grunfeld, Cancer Care Nova Scotia, Personal Communication.
 Grunfeld E, Zitzelsberger L, Coristine M, Whelan TJ, Aspelund F, Evans WK. Job stress and job satisfaction of cancer care workers. Psychooncology. 2005 Jan;14(1):61-9
 Elit L, Trim K, Mand-Bains IH, Sussman J, Grunfeld E; Society of Gynecologic Oncology Canada. Job satisfaction, stress, and burnout among Canadian gynecologic oncologists. Gynecol Oncol. 2004 Jul;94(1):134-9
 Grunfeld E, Whelan TJ, Zitzelsberger L, Willan AR, Montesanto B, Evans WK. Cancer care workers in Ontario: prevalence of burnout, job stress and job satisfaction. CMAJ. 2000 Jul 25;163(2):166-9.
 Supporting Doctors Ibid 63
 Ibid 31
 Ibid 37
 Ibid 39
 Ibid 50
 Ibid 55
 Ibid 56
 Ibid 58
 Ibid 59
 Ibid 60
 Ibid 78
 Ibid 70
 Ibid 72
 Ibid 78
 Ibid 74
 Subsequently (2004) the Healthcare Commission
 Supporting Doctors Ibid 75
 Ibid 77
 Assuring the Quality of Medical Practice: A summary of the responses to Supporting Doctors, protecting patients. NHS Executive 2001.
 Appendix: Selected Quotations
 Assuring the quality of medical practice: Implementing Supporting doctors protecting patients. Department of Health 2001 http://www.dh.gov.uk/assetRoot/04/08/46/19/04084619.pdf
 http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4006902&chk=j2Tt7C also HSSC 1998/113 http://www.dh.gov.uk/assetRoot/04/01/18/33/04011833.pdf
 Report of an expert group on learning from adverse events in the NHS chaired by the Chief Medical Officer http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4065083&chk=PARoiF
 "A framework through which NHS organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish."
G Scally and L J Donaldson, Clinical governance and the drive for quality improvement in the new NHS in England BMJ (4 July 1998): 61-65.
Clinical governance is based on Corporate Governance. It incorporates the four fundamental principles of quality outlined by the World Health Organisation – Technical Performance, Resource Efficiency, Minimising Risk, and Patient Satisfaction.
(The Principles of Quality Assurance. WHO Copenhagen 1983)
 Assuring the quality of medical practice 11
 Assuring the quality of medical practice 13
 Ibid 20
 Ibid 21
 Ibid 22
 Ibid 23
 Good Medical Practice. GMC http://www.gmc-uk.org/standards/good.htm
 Assuring the quality of medical practice 24
 Ibid 26
 Ibid 27
 Assuring the quality of medical practice Ibid 28
 Ibid 31
 Ibid 32
 Cadbury A. Report of the Committee on the Financial Aspects of Corporate Governance. Gee, London, 1992 (Cadbury Report) http://www.worldbank.org/html/fpd/privatesector/cg/docs/cadbury.pdf
 Berwick D. Continuous improvement as an ideal in health care. N Engl J Med 1989. 320: 53-56
 Kanter R. The change masters Allen and Unwin, London 1984.
 It is important to realise that moving away from blame does not mean abandoning accountability, which is a separate issue.
 New framework for discipline and suspension. Joint statement of agreed principles September 9th 2003. http://www.dh.gov.uk/assetRoot/04/06/99/57/04069957.PDF
 Follett B, Paulson-Ellis M. A Review of Appraisal, Disciplinary and Reporting Arrangements for Senior NHS and University Staff with Academic and Clinical Duties: A report to the Secretary of State for Education and Skills, September 2001. http://www.dfes.gov.uk/follettreview/
 Ibid p6
 Ibid p8
 Ibid p10
 Ibid p15
 Ibid p19
 Ibid p20
 Maintaining high professional standards in the modern NHS: Guidance on clinical academics. Department of Health April 2004. http://www.dh.gov.uk/assetRoot/04/08/06/78/04080678.PDF
 NCAA 2003/4 Annual Report
 http://www.ncaa.nhs.uk/toolkit/. Last accessed Dec 29 2004
 E.g. Csikszentmihalyi M. Finding Flow: The Psychology of Engagement With Everyday Life. Perseus, 1997
 West M, Markiewicz L. Building Team-based Working – A practical guide to organisational transformation. BPS Blackwell, 2004
 West, M.A., Borrill, C., Dawson, J., Scully, J., Carter, M., Anelay, S., Patterson, M., & Waring J. The link between the management of employees and patient mortality in acute hospitals. International Journal of Human Resource Management, 13: 1299-1310, 2002
 Pendleton D, King J. Values and leadership. BMJ 325: 1352-1355, 2002
Supplementary codes now exist for specialist physicians:
http://www.rcplondon.ac.uk/files/GoodMedicalPracticeForPhysicians.pdf, and for the various medical subspecialties, e.g Medical Oncology: http://www.rcplondon.ac.uk/files/gmpfp_ap13_medicaloncology.pdf
 68% of referrals involve behaviour
 Behavioural Coaching: http://www.behavioral-coaching-institute.com/Resources.html
 Advisory Handbook – Discipline & Grievances at Work: http://www.acas.org.uk/publications/h02.html
 Ibid 4
 Ibid 43
 Ibid 13
 Ibid 21
 Ibid 28
 Ibid 29
 Ibid 30
 Ibid 35
 Ibid 36
 Ibid 37
 Ibid 37
 Ibid 43
 Understanding Performance Difficulties in Doctors 44
 The Management of Suspensions of Clinical Staff in NHS Hospital and Ambulance Trusts in England Report By The Comptroller And Auditor General HC 1143 Session 2002-2003: 6 November 2003 http://www.nao.org.uk/publications/nao_reports/02-03/02031143.pdf
 The management of suspensions of clinical staff in NHS hospitals and ambulance trusts in England. Committee of Public Accounts, House of Commons. Forty–seventh Report of Session 2003–04 HC296 November 2004 http://www.publications.parliament.uk/pa/cm200304/cmselect/cmpubacc/296/296.pdf
 Auditor General’s Report 2003 p2
 Ibid 5
 Ibid 9
 Ibid 25
 Ibid 32
 Committee of Public Accounts 2004 p4
 Ibid 7
 Ibid. Evidence Mr Richard Bacon MP Q59
 Ibid Evidence 13
 Savage W: A Savage Enquiry Virago Press 1986.
 Advisory panel’s report to Tower Hamlets District Health Authority. BMJ 293: 1091-1092, 1986
 The trial of Mrs Wendy Savage. Lancet ii: 986, 1986
 Savage W. The Savage inquiry: a personal reply. BMJ 294: 775, 1987
 Learning from Bristol: the report of the public inquiry into children's heart surgery at the Bristol Royal Infirmary 1984 –1995 Command Paper: CM 5207 http://www.bristol-inquiry.org.uk/
 Learning from Bristol: Department of Health’s Response January 2002 http://www.dh.gov.uk/assetRoot/04/05/94/79/04059479.pdf
 Keogh B, Spiegelhalter D, Bailey A, Roxburgh J, Magee P, Hilton C. The legacy of Bristol: public disclosure of individual surgeons' results. BMJ. 2004 Aug 21;329(7463):450-4.
 Keogh op cit 450
 Doctor suspensions soar in wake of Bristol scandal. BBC 15 march 1999 http://news.bbc.co.uk/1/hi/health/background_briefings/the_bristol_heart_babies/163546.stm
 Learning from Bristol Summary 3-5, 7-8, 10-11
 Ibid 11
 Ibid 21
 Ibid 24
 Ibid 26-7
 Ibid 30
 Ibid 51
 Ibid 14
 Ibid 59
 Ibid 60
 Ibid 62
 Ibid 81-84, 86
 Ibid 92
 Ibid 98-102
 Learning from Bristol Summary 43
 Ibid Recommendations at 434
 Ibid at 436
 Inquiry into obstetric and gynaecological services at King Edward Memorial Hospital 1990-2000 http://www.health.wa.gov.au/kemhinquiry/
 Faunce TA, Bolsin SN. Three Australian whistleblowing sagas: lessons for internal and external regulation. Med J Aust. 2004 Jul 5;181(1):44-7.
 Open Disclosure Standard: A National Standard For Open Communication In Public And Private
Hospitals, Following An Adverse Event In Health Care. Australian Council For Safety And Quality In Health Care January 2003 http://Www.Safetyandquality.Org/Articles/Publications/Opendisclosure_Web.Pdf
 Special Commission of Inquiry into Camden and Campbelltown Hospitals http://www.findlaw.com.au/articles/default.asp?task=read&id=11894&site=GN
 Eagar K. The weakest link? Aust Health Rev. 2004;28(1):7-12.
 Holland J. HCCC Report and special commission of inquiry into Camden and Campbelltown Hospitals and Macarthur Health Service. Australian Health Law Bulletin 12(7): April 2004
 Ainsworth v Criminal Justice Commission (1992) 175 CLR 564
 Response to Supporting doctors, protecting patients
 Response to Supporting doctors, protecting patients
 Response to Supporting doctors, protecting patients
 Response to Supporting doctors, protecting patients
 Response to Supporting doctors, protecting patients
 Debate, Suspension of hospital doctors Bill, House of Lords 2000. BMJ 321: 72, 2000.
 BMJ 308: 1277-82, 1994
 BMJ 321: 72, 2000
 BMJ 317: 812, 1998
 Qual Saf Health Care 13: 58, 2004
 College of Physicians and Surgeons of Alberta. Complaint Process.
 Savage W: A Savage Enquiry Virago Press 1986. Cited in Auditor General’s report 2003
 Savage W. The Savage inquiry: a personal reply. BMJ 294: 775, 1987
 Advisory panel’s report to Tower Hamlets District Health Authority. BMJ 293: 1091-1092, 1986
 Learning from Bristol: the report of the public inquiry into children's heart surgery at the Bristol Royal Infirmary 1984 –1995 Command Paper: CM 5207
 NCAA Toolkit http://www.ncaa.nhs.uk/toolkit/
 NCAA Toolkit http://www.ncaa.nhs.uk/toolkit/
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 The Management of Suspensions of Clinical Staff in NHS Hospital and Ambulance Trusts in England, November 2003
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